"Procedure"|"Code Type"|"Revenue Code"|"Procedure Description"|"Quantity"|"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"
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.74||||1.74|0.77|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.74||||1.74|0.52|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.74||||1.74|0.82|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.74||||1.74|0.87|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.74||||1.74|0.87|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.74||||1.74|1.1|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.74||||1.74|0.52|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.74||||1.74|0.96|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.74||||1.74|1.2|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.74||||1.74|0.87|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.74||||1.74|0.77|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.74||||1.74|0.52|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.74||||1.74|0.77|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.74||||1.74|0.52|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.74||||1.74|0.52|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.74||||1.74|1.2|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.74||||1.74|0.52|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|Self-pay|Self-pay|1.74||||1.74|0.61|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.74||||1.74|0.52|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.74||||1.74|0.52|1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.74||||1.74||1.2|0.52
1000|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.74||||1.74||1.2|0.52
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|AARP [1000]|AARP [100000]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|AETNA [1015]|AETNA [101529]|13.27||||13.27|5.85|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.27||||13.27|3.94|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|BCBS [1155]|BCBS UTHCT [115568]|13.27||||13.27|6.24|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.27||||13.27|6.64|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.27||||13.27|6.64|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.27||||13.27|8.36|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.27||||13.27|3.94|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|CIGNA [1260]|CIGNA GWH [126023]|13.27||||13.27|7.3|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13.27||||13.27|9.16|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.27||||13.27|6.64|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.27||||13.27|5.85|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.27||||13.27|3.94|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.27||||13.27|5.85|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.27||||13.27|3.94|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.27||||13.27|3.94|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13.27||||13.27|9.16|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.27||||13.27|3.94|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|Self-pay|Self-pay|13.27||||13.27|4.64|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.27||||13.27|3.94|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.27||||13.27|3.94|9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.27||||13.27||9.16|3.94
10006|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"CATH IV 18 x 1.25"" VIAVALVE"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.27||||13.27||9.16|3.94
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.44||||0.44|0.19|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.44||||0.44|0.13|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.44||||0.44|0.21|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.44||||0.44|0.22|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.44||||0.44|0.22|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.44||||0.44|0.28|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.44||||0.44|0.13|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.44||||0.44|0.24|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.44||||0.44|0.3|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.44||||0.44|0.22|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.44||||0.44|0.19|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.44||||0.44|0.13|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.44||||0.44|0.19|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.44||||0.44|0.13|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.44||||0.44|0.13|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.44||||0.44|0.3|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.44||||0.44|0.13|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.44||||0.44|0.15|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.44||||0.44|0.13|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.44||||0.44|0.13|0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.44||||0.44||0.3|0.13
10011|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.44||||0.44||0.3|0.13
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|AARP [1000]|AARP [100000]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|AETNA [1015]|AETNA [101529]|24.26||||24.26|10.7|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.26||||24.26|7.19|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|BCBS [1155]|BCBS UTHCT [115568]|24.26||||24.26|11.4|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.26||||24.26|12.13|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.26||||24.26|12.13|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.26||||24.26|15.28|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.26||||24.26|7.19|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|CIGNA [1260]|CIGNA GWH [126023]|24.26||||24.26|13.34|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|24.26||||24.26|16.74|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.26||||24.26|12.13|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.26||||24.26|10.7|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.26||||24.26|7.19|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.26||||24.26|10.7|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.26||||24.26|7.19|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.26||||24.26|7.19|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|24.26||||24.26|16.74|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.26||||24.26|7.19|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|Self-pay|Self-pay|24.26||||24.26|8.49|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.26||||24.26|7.19|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.26||||24.26|7.19|16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.26||||24.26||16.74|7.19
10012|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|BAG LEG URINARY DRAINAGE STERILE BOTTOM DRAINS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.26||||24.26||16.74|7.19
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|AARP [1000]|AARP [100000]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|AETNA [1015]|AETNA [101529]|21.1||||21.1|9.3|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.1||||21.1|6.25|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|BCBS [1155]|BCBS UTHCT [115568]|21.1||||21.1|9.92|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.1||||21.1|10.55|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.1||||21.1|10.55|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.1||||21.1|13.29|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.1||||21.1|6.25|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|CIGNA [1260]|CIGNA GWH [126023]|21.1||||21.1|11.6|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|21.1||||21.1|14.56|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.1||||21.1|10.55|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.1||||21.1|9.3|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.1||||21.1|6.25|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.1||||21.1|9.3|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.1||||21.1|6.25|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.1||||21.1|6.25|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|21.1||||21.1|14.56|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.1||||21.1|6.25|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|Self-pay|Self-pay|21.1||||21.1|7.39|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.1||||21.1|6.25|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.1||||21.1|6.25|14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.1||||21.1||14.56|6.25
10013|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER EXTERNAL MALE URINARY SOFT LATEX SHEATH DRAINA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.1||||21.1||14.56|6.25
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AARP [1000]|AARP [100000]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AETNA [1015]|AETNA [101529]|136.4||||136.4|60.15|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136.4||||136.4|40.44|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS [1155]|BCBS UTHCT [115568]|136.4||||136.4|64.11|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136.4||||136.4|68.2|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136.4||||136.4|68.2|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136.4||||136.4|85.93|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136.4||||136.4|40.44|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|CIGNA [1260]|CIGNA GWH [126023]|136.4||||136.4|75.02|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|136.4||||136.4|94.12|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|136.4||||136.4|68.2|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136.4||||136.4|60.15|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136.4||||136.4|40.44|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136.4||||136.4|60.15|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136.4||||136.4|40.44|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|136.4||||136.4|40.44|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|136.4||||136.4|94.12|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136.4||||136.4|40.44|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|Self-pay|Self-pay|136.4||||136.4|47.74|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|136.4||||136.4|40.44|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136.4||||136.4|40.44|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136.4||||136.4||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|AARP [1000]|AARP [100000]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|AETNA [1015]|AETNA [101529]|120.9||||120.9|53.32|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|120.9||||120.9|35.85|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|BCBS [1155]|BCBS UTHCT [115568]|120.9||||120.9|56.82|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|120.9||||120.9|60.45|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|120.9||||120.9|60.45|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|120.9||||120.9|76.17|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|120.9||||120.9|35.85|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|CIGNA [1260]|CIGNA GWH [126023]|120.9||||120.9|66.5|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|120.9||||120.9|83.42|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|120.9||||120.9|60.45|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|120.9||||120.9|53.32|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|120.9||||120.9|35.85|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|120.9||||120.9|53.32|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|120.9||||120.9|35.85|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|120.9||||120.9|35.85|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|120.9||||120.9|83.42|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|120.9||||120.9|35.85|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|Self-pay|Self-pay|120.9||||120.9|42.31|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|120.9||||120.9|35.85|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|120.9||||120.9|35.85|94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|120.9||||120.9||94.12|20.2
10014|ERX|0250 - PHARMACY-GENERAL|FAT EMULSION 20 % INTRAVENOUS|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|120.9||||120.9||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|AARP [1000]|AARP [100000]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|AETNA [1015]|AETNA [101529]|68.12||||68.12|30.04|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|68.12||||68.12|20.2|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|BCBS [1155]|BCBS UTHCT [115568]|68.12||||68.12|32.02|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|68.12||||68.12|34.06|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|68.12||||68.12|34.06|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|68.12||||68.12|42.92|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|68.12||||68.12|20.2|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|CIGNA [1260]|CIGNA GWH [126023]|68.12||||68.12|37.47|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|68.12||||68.12|47|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|68.12||||68.12|34.06|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|68.12||||68.12|30.04|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|68.12||||68.12|20.2|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|68.12||||68.12|30.04|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|68.12||||68.12|20.2|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|68.12||||68.12|20.2|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|68.12||||68.12|47|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|68.12||||68.12|20.2|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|Self-pay|Self-pay|68.12||||68.12|23.84|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|68.12||||68.12|20.2|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|68.12||||68.12|20.2|94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|68.12||||68.12||94.12|20.2
10014|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 10FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|68.12||||68.12||94.12|20.2
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|AARP [1000]|AARP [100000]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|AETNA [1015]|AETNA [101529]|54.06||||54.06|23.84|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54.06||||54.06|16.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|BCBS [1155]|BCBS UTHCT [115568]|54.06||||54.06|25.41|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54.06||||54.06|27.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54.06||||54.06|27.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54.06||||54.06|34.06|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54.06||||54.06|16.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|CIGNA [1260]|CIGNA GWH [126023]|54.06||||54.06|29.73|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54.06||||54.06|37.3|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54.06||||54.06|27.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54.06||||54.06|23.84|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54.06||||54.06|16.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54.06||||54.06|23.84|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54.06||||54.06|16.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54.06||||54.06|16.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54.06||||54.06|37.3|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54.06||||54.06|16.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|Self-pay|Self-pay|54.06||||54.06|18.92|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54.06||||54.06|16.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54.06||||54.06|16.03|37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54.06||||54.06||37.3|16.03
10015|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 12 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54.06||||54.06||37.3|16.03
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|AARP [1000]|AARP [100000]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|AETNA [1015]|AETNA [101529]|20.74||||20.74|9.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.74||||20.74|6.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|BCBS [1155]|BCBS UTHCT [115568]|20.74||||20.74|9.75|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.74||||20.74|10.37|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.74||||20.74|10.37|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.74||||20.74|13.07|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.74||||20.74|6.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|CIGNA [1260]|CIGNA GWH [126023]|20.74||||20.74|11.41|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20.74||||20.74|14.31|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.74||||20.74|10.37|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.74||||20.74|9.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.74||||20.74|6.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.74||||20.74|9.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.74||||20.74|6.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.74||||20.74|6.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20.74||||20.74|14.31|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.74||||20.74|6.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|Self-pay|Self-pay|20.74||||20.74|7.26|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.74||||20.74|6.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.74||||20.74|6.15|14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.74||||20.74||14.31|6.15
10016|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY URETHRAL 16 FR 5 CC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.74||||20.74||14.31|6.15
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|AARP [1000]|AARP [100000]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|AETNA [1015]|AETNA [101529]|35.34||||35.34|15.58|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.34||||35.34|10.48|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|BCBS [1155]|BCBS UTHCT [115568]|35.34||||35.34|16.61|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.34||||35.34|17.67|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.34||||35.34|17.67|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.34||||35.34|22.26|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.34||||35.34|10.48|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|CIGNA [1260]|CIGNA GWH [126023]|35.34||||35.34|19.43|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|35.34||||35.34|24.38|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35.34||||35.34|17.67|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.34||||35.34|15.58|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.34||||35.34|10.48|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.34||||35.34|15.58|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.34||||35.34|10.48|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|35.34||||35.34|10.48|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|35.34||||35.34|24.38|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.34||||35.34|10.48|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|Self-pay|Self-pay|35.34||||35.34|12.37|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35.34||||35.34|10.48|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.34||||35.34|10.48|24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.34||||35.34||24.38|10.48
10017|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY FOLEY 16 FR W/O BAG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.34||||35.34||24.38|10.48
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|AARP [1000]|AARP [100000]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|AETNA [1015]|AETNA [101529]|111.23||||111.23|49.05|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111.23||||111.23|32.98|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|BCBS [1155]|BCBS UTHCT [115568]|111.23||||111.23|52.28|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111.23||||111.23|55.61|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111.23||||111.23|55.61|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111.23||||111.23|70.07|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111.23||||111.23|32.98|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|CIGNA [1260]|CIGNA GWH [126023]|111.23||||111.23|61.18|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|111.23||||111.23|76.75|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|111.23||||111.23|55.61|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111.23||||111.23|49.05|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111.23||||111.23|32.98|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111.23||||111.23|49.05|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111.23||||111.23|32.98|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|111.23||||111.23|32.98|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|111.23||||111.23|76.75|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111.23||||111.23|32.98|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|Self-pay|Self-pay|111.23||||111.23|38.93|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|111.23||||111.23|32.98|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111.23||||111.23|32.98|76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111.23||||111.23||76.75|32.98
10018|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRAY CATHETERZATION IC 16FR. W/STATLOCK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111.23||||111.23||76.75|32.98
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|AARP [1000]|AARP [100000]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|AETNA [1015]|AETNA [101529]|19.51||||19.51|8.61|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.51||||19.51|5.79|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|BCBS [1155]|BCBS UTHCT [115568]|19.51||||19.51|9.17|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.51||||19.51|9.76|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.51||||19.51|9.76|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.51||||19.51|12.29|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.51||||19.51|5.79|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|CIGNA [1260]|CIGNA GWH [126023]|19.51||||19.51|10.73|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|19.51||||19.51|13.46|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.51||||19.51|9.76|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.51||||19.51|8.61|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.51||||19.51|5.79|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.51||||19.51|8.61|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.51||||19.51|5.79|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.51||||19.51|5.79|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|19.51||||19.51|13.46|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.51||||19.51|5.79|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|Self-pay|Self-pay|19.51||||19.51|6.83|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.51||||19.51|5.79|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.51||||19.51|5.79|13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.51||||19.51||13.46|5.79
10020|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRAINAGE BAG SINGLE STERILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.51||||19.51||13.46|5.79
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|AARP [1000]|AARP [100000]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|AETNA [1015]|AETNA [101529]|53.44||||53.44|23.57|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|53.44||||53.44|15.85|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|BCBS [1155]|BCBS UTHCT [115568]|53.44||||53.44|25.12|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|53.44||||53.44|26.72|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|53.44||||53.44|26.72|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|53.44||||53.44|33.67|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|53.44||||53.44|15.85|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|CIGNA [1260]|CIGNA GWH [126023]|53.44||||53.44|29.39|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|53.44||||53.44|36.88|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|53.44||||53.44|26.72|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|53.44||||53.44|23.57|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|53.44||||53.44|15.85|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|53.44||||53.44|23.57|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|53.44||||53.44|15.85|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|53.44||||53.44|15.85|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|53.44||||53.44|36.88|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|53.44||||53.44|15.85|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|Self-pay|Self-pay|53.44||||53.44|18.7|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|53.44||||53.44|15.85|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|53.44||||53.44|15.85|36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|53.44||||53.44||36.88|15.85
10021|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE MEASURE WITH BAG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|53.44||||53.44||36.88|15.85
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|AARP [1000]|AARP [100000]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|AETNA [1015]|AETNA [101529]|147.66||||147.66|65.12|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|147.66||||147.66|43.78|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|BCBS [1155]|BCBS UTHCT [115568]|147.66||||147.66|69.4|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|147.66||||147.66|73.83|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|147.66||||147.66|73.83|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|147.66||||147.66|93.02|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|147.66||||147.66|43.78|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|CIGNA [1260]|CIGNA GWH [126023]|147.66||||147.66|81.21|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|147.66||||147.66|101.88|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|147.66||||147.66|73.83|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|147.66||||147.66|65.12|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|147.66||||147.66|43.78|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|147.66||||147.66|65.12|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|147.66||||147.66|43.78|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|147.66||||147.66|43.78|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|147.66||||147.66|101.88|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|147.66||||147.66|43.78|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|Self-pay|Self-pay|147.66||||147.66|51.68|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|147.66||||147.66|43.78|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|147.66||||147.66|43.78|101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|147.66||||147.66||101.88|43.78
10022|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URINE METER IC FOLEY TRAY 16 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|147.66||||147.66||101.88|43.78
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|AARP [1000]|AARP [100000]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|AETNA [1015]|AETNA [101529]|1575.2||||1575.2|694.66|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1575.2||||1575.2|467.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|BCBS [1155]|BCBS UTHCT [115568]|1575.2||||1575.2|740.34|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1575.2||||1575.2|787.6|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1575.2||||1575.2|787.6|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1575.2||||1575.2|992.38|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1575.2||||1575.2|467.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|CIGNA [1260]|CIGNA GWH [126023]|1575.2||||1575.2|866.36|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1575.2||||1575.2|1086.89|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1575.2||||1575.2|787.6|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1575.2||||1575.2|694.66|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1575.2||||1575.2|467.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1575.2||||1575.2|694.66|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1575.2||||1575.2|467.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1575.2||||1575.2|467.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1575.2||||1575.2|1086.89|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1575.2||||1575.2|467.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|Self-pay|Self-pay|1575.2||||1575.2|551.32|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1575.2||||1575.2|467.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1575.2||||1575.2|467.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|237 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1575.2||||1575.2||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|106.69||||106.69|47.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|106.69||||106.69|31.63|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|106.69||||106.69|50.14|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|106.69||||106.69|53.35|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|106.69||||106.69|53.35|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|106.69||||106.69|67.21|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|106.69||||106.69|31.63|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|106.69||||106.69|58.68|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|106.69||||106.69|73.62|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|106.69||||106.69|53.35|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106.69||||106.69|47.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|106.69||||106.69|31.63|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|106.69||||106.69|47.05|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|106.69||||106.69|31.63|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|106.69||||106.69|31.63|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|106.69||||106.69|73.62|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|106.69||||106.69|31.63|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|106.69||||106.69|37.34|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|106.69||||106.69|31.63|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|106.69||||106.69|31.63|1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|106.69||||106.69||1086.89|31.63
10023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FELBAMATE 600 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|106.69||||106.69||1086.89|31.63
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|AARP [1000]|AARP [100000]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|AETNA [1015]|AETNA [101529]|88.11||||88.11|38.86|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|88.11||||88.11|26.13|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|BCBS [1155]|BCBS UTHCT [115568]|88.11||||88.11|41.41|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|88.11||||88.11|0|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|88.11||||88.11|44.06|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|88.11||||88.11|55.51|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|88.11||||88.11|26.13|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|CIGNA [1260]|CIGNA GWH [126023]|88.11||||88.11|48.46|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|88.11||||88.11|60.8|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|88.11||||88.11|44.06|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|88.11||||88.11|38.86|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|88.11||||88.11|26.13|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|88.11||||88.11|38.86|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|88.11||||88.11|26.13|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|88.11||||88.11|26.13|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|88.11||||88.11|60.8|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|88.11||||88.11|26.13|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|Self-pay|Self-pay|88.11||||88.11|30.84|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|88.11||||88.11|26.13|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|88.11||||88.11|26.13|60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|88.11||||88.11||60.8|26.13
10025|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY CARSON 16 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|88.11||||88.11||60.8|26.13
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|AARP [1000]|AARP [100000]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|AETNA [1015]|AETNA [101529]|213.54||||213.54|94.17|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|213.54||||213.54|63.32|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|BCBS [1155]|BCBS UTHCT [115568]|213.54||||213.54|100.37|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|213.54||||213.54|106.77|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|213.54||||213.54|106.77|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|213.54||||213.54|134.53|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|213.54||||213.54|63.32|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|CIGNA [1260]|CIGNA GWH [126023]|213.54||||213.54|117.45|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|213.54||||213.54|147.35|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|213.54||||213.54|106.77|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|213.54||||213.54|94.17|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|213.54||||213.54|63.32|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|213.54||||213.54|94.17|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|213.54||||213.54|63.32|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|213.54||||213.54|63.32|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|213.54||||213.54|147.35|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|213.54||||213.54|63.32|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|Self-pay|Self-pay|213.54||||213.54|74.74|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|213.54||||213.54|63.32|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|213.54||||213.54|63.32|147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|213.54||||213.54||147.35|63.32
10027|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER TRAY CRITICORE IC FOLEY 16 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|213.54||||213.54||147.35|63.32
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|AARP [1000]|AARP [100000]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|AETNA [1015]|AETNA [101529]|2.99||||2.99|1.32|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.99||||2.99|0.89|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|BCBS [1155]|BCBS UTHCT [115568]|2.99||||2.99|1.4|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.99||||2.99|1.49|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.99||||2.99|1.49|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.99||||2.99|1.88|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.99||||2.99|0.89|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|CIGNA [1260]|CIGNA GWH [126023]|2.99||||2.99|1.64|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2.99||||2.99|2.06|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.99||||2.99|1.49|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.99||||2.99|1.32|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.99||||2.99|0.89|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.99||||2.99|1.32|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.99||||2.99|0.89|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.99||||2.99|0.89|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2.99||||2.99|2.06|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.99||||2.99|0.89|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|Self-pay|Self-pay|2.99||||2.99|1.05|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.99||||2.99|0.89|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.99||||2.99|0.89|2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.99||||2.99||2.06|0.89
10029|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/CONTROL VENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.99||||2.99||2.06|0.89
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|AARP [1000]|AARP [100000]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|AETNA [1015]|AETNA [101529]|3.25||||3.25|1.43|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.25||||3.25|0.96|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|BCBS [1155]|BCBS UTHCT [115568]|3.25||||3.25|1.53|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.25||||3.25|1.63|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.25||||3.25|1.63|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.25||||3.25|2.05|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.25||||3.25|0.96|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|CIGNA [1260]|CIGNA GWH [126023]|3.25||||3.25|1.79|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3.25||||3.25|2.24|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.25||||3.25|1.63|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.25||||3.25|1.43|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.25||||3.25|0.96|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.25||||3.25|1.43|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.25||||3.25|0.96|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.25||||3.25|0.96|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3.25||||3.25|2.24|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.25||||3.25|0.96|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|Self-pay|Self-pay|3.25||||3.25|1.14|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.25||||3.25|0.96|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.25||||3.25|0.96|2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.25||||3.25||2.24|0.96
10030|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION INSTRUMENT SURGICAL YANKAUER W/O CONTROL VENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.25||||3.25||2.24|0.96
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|AARP [1000]|AARP [100000]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|AETNA [1015]|AETNA [101529]|249.94||||249.94|110.22|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|249.94||||249.94|74.11|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|BCBS [1155]|BCBS UTHCT [115568]|249.94||||249.94|117.47|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|249.94||||249.94|124.97|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|249.94||||249.94|124.97|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|249.94||||249.94|157.46|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|249.94||||249.94|74.11|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|CIGNA [1260]|CIGNA GWH [126023]|249.94||||249.94|137.47|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|249.94||||249.94|172.46|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|249.94||||249.94|124.97|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|249.94||||249.94|110.22|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|249.94||||249.94|74.11|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|249.94||||249.94|110.22|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|249.94||||249.94|74.11|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|249.94||||249.94|74.11|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|249.94||||249.94|172.46|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|249.94||||249.94|74.11|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|Self-pay|Self-pay|249.94||||249.94|87.48|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|249.94||||249.94|74.11|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|249.94||||249.94|74.11|172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|249.94||||249.94||172.46|74.11
10033|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CHEST DRAIN EXPRESS DRY CONTROL SINGLE COLLECTION 1 PT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|249.94||||249.94||172.46|74.11
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|AARP [1000]|AARP [100000]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|AETNA [1015]|AETNA [101529]|9915.82||||9915.82|4372.88|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9915.82||||9915.82|2940.04|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|BCBS [1155]|BCBS UTHCT [115568]|9915.82||||9915.82|4660.44|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9915.82||||9915.82|4957.91|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9915.82||||9915.82|4957.91|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9915.82||||9915.82|6246.97|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9915.82||||9915.82|2940.04|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|CIGNA [1260]|CIGNA GWH [126023]|9915.82||||9915.82|4957.91|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|9915.82||||9915.82|6841.92|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9915.82||||9915.82|4957.91|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9915.82||||9915.82|4372.88|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9915.82||||9915.82|2940.04|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9915.82||||9915.82|4372.88|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9915.82||||9915.82|2940.04|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|9915.82||||9915.82|2940.04|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|9915.82||||9915.82|6841.92|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9915.82||||9915.82|2940.04|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|Self-pay|Self-pay|9915.82||||9915.82|3470.54|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9915.82||||9915.82|2940.04|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9915.82||||9915.82|2940.04|6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9915.82||||9915.82||6841.92|2940.04
100344|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIDEPSIN 10 MG/2 ML INTRAVENOUS POWDER FOR SOLUTION|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9915.82||||9915.82||6841.92|2940.04
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|975.98||||975.98|354|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|975.98||||975.98|294.52|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|975.98||||975.98|662.4|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|975.98||||975.98|289.38|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|975.98||||975.98|291.6|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|975.98||||975.98|291.6|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|975.98||||975.98|458.71|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|975.98||||975.98|0|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|975.98||||975.98|487.99|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|975.98||||975.98|614.87|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|975.98||||975.98|289.38|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|975.98||||975.98|291.6|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|975.98||||975.98|487.99|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|975.98||||975.98|673.43|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|975.98||||975.98|1.18|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|975.98||||975.98|291.6|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|975.98||||975.98|662.4|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|975.98||||975.98|289.38|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|975.98||||975.98|291.6|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|975.98||||975.98|662.4|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|975.98||||975.98|289.38|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|975.98||||975.98|289.38|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|975.98||||975.98|673.43|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|975.98||||975.98|289.38|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|975.98||||975.98|341.59|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|975.98||||975.98|289.38|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|975.98||||975.98|289.38|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|975.98||||975.98|354|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|975.98||||975.98|291.6|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|975.98||||975.98|291.6|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|975.98||||975.98|354|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|975.98||||975.98|291.6|673.43|1.18
10036|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|975.98||||975.98|583.2|673.43|1.18
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.19||||1.19|0.52|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.19||||1.19|0.35|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.19||||1.19|0.56|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.19||||1.19|0.6|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.19||||1.19|0.6|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.19||||1.19|0.75|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.19||||1.19|0.35|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.19||||1.19|0.65|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.19||||1.19|0.82|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.19||||1.19|0.6|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.19||||1.19|0.52|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.19||||1.19|0.35|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.19||||1.19|0.52|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.19||||1.19|0.35|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.19||||1.19|0.35|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.19||||1.19|0.82|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.19||||1.19|0.35|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.19||||1.19|0.42|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.19||||1.19|0.35|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.19||||1.19|0.35|0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.19||||1.19||0.82|0.35
10037|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.19||||1.19||0.82|0.35
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|AARP [1000]|AARP [100000]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|AETNA [1015]|AETNA [101529]|363.27||||363.27|160.2|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|363.27||||363.27|107.71|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|363.27||||363.27|170.74|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|363.27||||363.27|181.64|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|363.27||||363.27|181.64|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|363.27||||363.27|228.86|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|363.27||||363.27|107.71|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|363.27||||363.27|199.8|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|363.27||||363.27|250.66|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|363.27||||363.27|181.64|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|363.27||||363.27|160.2|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|363.27||||363.27|107.71|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|363.27||||363.27|160.2|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|363.27||||363.27|107.71|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|363.27||||363.27|107.71|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|363.27||||363.27|250.66|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|363.27||||363.27|107.71|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|Self-pay|Self-pay|363.27||||363.27|127.14|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|363.27||||363.27|107.71|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|363.27||||363.27|107.71|250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|363.27||||363.27||250.66|107.71
100393|ERX|0250 - PHARMACY-GENERAL|AZTREONAM LYSINE 75 MG/ML SOLUTION FOR NEBULIZATION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|363.27||||363.27||250.66|107.71
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.91||||2.91|1.28|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.91||||2.91|0.86|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.91||||2.91|1.37|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.91||||2.91|1.46|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.91||||2.91|1.46|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.91||||2.91|1.83|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.91||||2.91|0.86|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.91||||2.91|1.6|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.91||||2.91|2.01|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.91||||2.91|1.46|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.91||||2.91|1.28|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.91||||2.91|0.86|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.91||||2.91|1.28|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.91||||2.91|0.86|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.91||||2.91|0.86|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.91||||2.91|2.01|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.91||||2.91|0.86|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|Self-pay|Self-pay|2.91||||2.91|1.02|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.91||||2.91|0.86|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.91||||2.91|0.86|2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.91||||2.91||2.01|0.86
10041|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.91||||2.91||2.01|0.86
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.78||||1.78|0.78|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.78||||1.78|0.53|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.78||||1.78|0.84|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.78||||1.78|0.89|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.78||||1.78|0.89|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.78||||1.78|1.12|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.78||||1.78|0.53|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.78||||1.78|0.98|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.78||||1.78|1.23|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.78||||1.78|0.89|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.78||||1.78|0.78|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.78||||1.78|0.53|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.78||||1.78|0.78|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.78||||1.78|0.53|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.78||||1.78|0.53|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.78||||1.78|1.23|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.78||||1.78|0.53|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.78||||1.78|0.62|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.78||||1.78|0.53|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.78||||1.78|0.53|92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.78||||1.78||92.8|0.53
10043|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLECAINIDE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.78||||1.78||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|AARP [1000]|AARP [100000]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|AETNA [1015]|AETNA [101529]|134.49||||134.49|59.31|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|134.49||||134.49|39.88|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|BCBS [1155]|BCBS UTHCT [115568]|134.49||||134.49|63.21|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|134.49||||134.49|67.25|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|134.49||||134.49|67.25|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|134.49||||134.49|84.73|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|134.49||||134.49|39.88|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|CIGNA [1260]|CIGNA GWH [126023]|134.49||||134.49|73.97|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|134.49||||134.49|92.8|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|134.49||||134.49|67.25|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|134.49||||134.49|59.31|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|134.49||||134.49|39.88|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|134.49||||134.49|59.31|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|134.49||||134.49|39.88|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|134.49||||134.49|39.88|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|134.49||||134.49|92.8|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|134.49||||134.49|39.88|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|Self-pay|Self-pay|134.49||||134.49|47.07|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|134.49||||134.49|39.88|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|134.49||||134.49|39.88|92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|134.49||||134.49||92.8|0.53
10043|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ELECTRODE DEFIBRILLATION/ECG QUICKCOMBO FOR USE WITH LIFE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|134.49||||134.49||92.8|0.53
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.64||||4.64|2.05|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.64||||4.64|1.38|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.64||||4.64|2.18|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.64||||4.64|2.32|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.64||||4.64|2.32|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.64||||4.64|2.92|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.64||||4.64|1.38|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.64||||4.64|2.55|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.64||||4.64|3.2|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.64||||4.64|2.32|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.64||||4.64|2.05|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.64||||4.64|1.38|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.64||||4.64|2.05|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.64||||4.64|1.38|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.64||||4.64|1.38|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.64||||4.64|3.2|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.64||||4.64|1.38|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|Self-pay|Self-pay|4.64||||4.64|1.62|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.64||||4.64|1.38|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.64||||4.64|1.38|14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.64||||4.64||14.56|1.38
10044|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.64||||4.64||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|AARP [1000]|AARP [100000]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|AETNA [1015]|AETNA [101529]|21.1||||21.1|9.3|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.1||||21.1|6.25|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|BCBS [1155]|BCBS UTHCT [115568]|21.1||||21.1|9.92|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.1||||21.1|10.55|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.1||||21.1|10.55|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.1||||21.1|13.29|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.1||||21.1|6.25|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|CIGNA [1260]|CIGNA GWH [126023]|21.1||||21.1|11.6|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|21.1||||21.1|14.56|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.1||||21.1|10.55|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.1||||21.1|9.3|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.1||||21.1|6.25|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.1||||21.1|9.3|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.1||||21.1|6.25|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.1||||21.1|6.25|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|21.1||||21.1|14.56|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.1||||21.1|6.25|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|Self-pay|Self-pay|21.1||||21.1|7.39|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.1||||21.1|6.25|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.1||||21.1|6.25|14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.1||||21.1||14.56|1.38
10044|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE GROUNDING PAD PATIENT RETURN REM COMPATIBLE PO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.1||||21.1||14.56|1.38
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AARP [1000]|AARP [100000]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA [1015]|AETNA [101529]|292.95||||292.95|121.78|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|292.95||||292.95|86.86|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BCBS UTHCT [115568]|292.95||||292.95|137.69|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|292.95||||292.95|0|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|292.95||||292.95|146.48|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|292.95||||292.95|184.56|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|292.95||||292.95|86.86|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA GWH [126023]|292.95||||292.95|161.12|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|292.95||||292.95|202.14|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|292.95||||292.95|59.41|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|292.95||||292.95|121.78|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|292.95||||292.95|86.86|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|292.95||||292.95|121.78|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|292.95||||292.95|86.86|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|292.95||||292.95|86.86|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|292.95||||292.95|202.14|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|292.95||||292.95|86.86|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|Self-pay|Self-pay|292.95||||292.95|102.53|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|292.95||||292.95|86.86|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|292.95||||292.95|86.86|202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|292.95||||292.95||202.14|5.39
10053|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUDARABINE 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|292.95||||292.95||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|AARP [1000]|AARP [100000]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|AETNA [1015]|AETNA [101529]|18.2||||18.2|8.02|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.2||||18.2|5.39|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|BCBS [1155]|BCBS UTHCT [115568]|18.2||||18.2|8.55|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.2||||18.2|9.1|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.2||||18.2|9.1|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.2||||18.2|11.46|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.2||||18.2|5.39|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|CIGNA [1260]|CIGNA GWH [126023]|18.2||||18.2|10.01|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|18.2||||18.2|12.55|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.2||||18.2|9.1|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.2||||18.2|8.02|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.2||||18.2|5.39|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.2||||18.2|8.02|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.2||||18.2|5.39|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.2||||18.2|5.39|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|18.2||||18.2|12.55|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.2||||18.2|5.39|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|Self-pay|Self-pay|18.2||||18.2|6.37|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.2||||18.2|5.39|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.2||||18.2|5.39|202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.2||||18.2||202.14|5.39
10053|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|STOCKINGS ANTI-EMBOLISM KNEE LENGTHSMALL-REGULAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.2||||18.2||202.14|5.39
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.62||||2.62|1.16|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.62||||2.62|0.78|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.62||||2.62|1.23|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.62||||2.62|1.31|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.62||||2.62|1.31|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.62||||2.62|1.65|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.62||||2.62|0.78|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.62||||2.62|1.44|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.62||||2.62|1.81|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.62||||2.62|1.31|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.62||||2.62|1.16|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.62||||2.62|0.78|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.62||||2.62|1.16|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.62||||2.62|0.78|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.62||||2.62|0.78|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.62||||2.62|1.81|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.62||||2.62|0.78|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|Self-pay|Self-pay|2.62||||2.62|0.92|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.62||||2.62|0.78|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.62||||2.62|0.78|17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.62||||2.62||17.41|0.78
10054|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.62||||2.62||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|AARP [1000]|AARP [100000]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|AETNA [1015]|AETNA [101529]|25.23||||25.23|11.13|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.23||||25.23|7.48|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|BCBS [1155]|BCBS UTHCT [115568]|25.23||||25.23|11.86|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.23||||25.23|12.61|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.23||||25.23|12.61|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.23||||25.23|15.89|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.23||||25.23|7.48|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|CIGNA [1260]|CIGNA GWH [126023]|25.23||||25.23|13.88|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|25.23||||25.23|17.41|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25.23||||25.23|12.61|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.23||||25.23|11.13|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.23||||25.23|7.48|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.23||||25.23|11.13|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.23||||25.23|7.48|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|25.23||||25.23|7.48|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|25.23||||25.23|17.41|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.23||||25.23|7.48|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|Self-pay|Self-pay|25.23||||25.23|8.83|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25.23||||25.23|7.48|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.23||||25.23|7.48|17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.23||||25.23||17.41|0.78
10054|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE MEDIUM-REGULAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.23||||25.23||17.41|0.78
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|AARP [1000]|AARP [100000]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|AETNA [1015]|AETNA [101529]|27.07||||27.07|11.94|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.07||||27.07|8.03|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|BCBS [1155]|BCBS UTHCT [115568]|27.07||||27.07|12.72|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.07||||27.07|13.54|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.07||||27.07|13.54|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.07||||27.07|17.06|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.07||||27.07|8.03|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|CIGNA [1260]|CIGNA GWH [126023]|27.07||||27.07|14.89|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|27.07||||27.07|18.68|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.07||||27.07|13.54|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.07||||27.07|11.94|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.07||||27.07|8.03|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.07||||27.07|11.94|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.07||||27.07|8.03|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.07||||27.07|8.03|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|27.07||||27.07|18.68|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.07||||27.07|8.03|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|Self-pay|Self-pay|27.07||||27.07|9.47|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.07||||27.07|8.03|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.07||||27.07|8.03|18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.07||||27.07||18.68|8.03
10055|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HOSE ANTI-EMBOLISM BELOW KNEE LARGE-REGULAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.07||||27.07||18.68|8.03
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|AARP [1000]|AARP [100000]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|AETNA [1015]|AETNA [101529]|3525.45||||3525.45|2838.24|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3525.45||||3525.45|1045.3|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|BCBS [1155]|BCBS UTHCT [115568]|3525.45||||3525.45|1656.96|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3525.45||||3525.45|0|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3525.45||||3525.45|1762.73|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3525.45||||3525.45|2221.03|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3525.45||||3525.45|1045.3|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|CIGNA [1260]|CIGNA GWH [126023]|3525.45||||3525.45|1762.73|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|3525.45||||3525.45|2432.56|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3525.45||||3525.45|3.65|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3525.45||||3525.45|2838.24|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3525.45||||3525.45|1045.3|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3525.45||||3525.45|2838.24|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3525.45||||3525.45|1045.3|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|3525.45||||3525.45|1045.3|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|3525.45||||3525.45|2432.56|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3525.45||||3525.45|1045.3|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|Self-pay|Self-pay|3525.45||||3525.45|1233.91|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3525.45||||3525.45|1045.3|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3525.45||||3525.45|1045.3|2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3525.45||||3525.45||2838.24|3.65
100552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OLANZAPINE PAMOATE 405 MG INTRAMUSCULAR SUSPENSION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3525.45||||3525.45||2838.24|3.65
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|AARP [1000]|AARP [100000]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|AETNA [1015]|AETNA [101529]|9.23||||9.23|4.07|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.23||||9.23|2.74|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|BCBS [1155]|BCBS UTHCT [115568]|9.23||||9.23|4.34|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.23||||9.23|4.61|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.23||||9.23|4.61|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.23||||9.23|5.81|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.23||||9.23|2.74|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|CIGNA [1260]|CIGNA GWH [126023]|9.23||||9.23|5.08|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9.23||||9.23|6.37|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.23||||9.23|4.61|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.23||||9.23|4.07|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.23||||9.23|2.74|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.23||||9.23|4.07|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.23||||9.23|2.74|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.23||||9.23|2.74|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9.23||||9.23|6.37|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.23||||9.23|2.74|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|Self-pay|Self-pay|9.23||||9.23|3.23|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.23||||9.23|2.74|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.23||||9.23|2.74|6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.23||||9.23||6.37|2.74
10056|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL 22 GA X 3 1/2"" DISP"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.23||||9.23||6.37|2.74
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|AARP [1000]|AARP [100000]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|AETNA [1015]|AETNA [101529]|84.6||||84.6|37.31|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84.6||||84.6|25.08|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|BCBS [1155]|BCBS UTHCT [115568]|84.6||||84.6|39.76|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84.6||||84.6|42.3|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84.6||||84.6|42.3|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84.6||||84.6|53.3|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84.6||||84.6|25.08|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|CIGNA [1260]|CIGNA GWH [126023]|84.6||||84.6|46.53|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|84.6||||84.6|58.37|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|84.6||||84.6|42.3|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84.6||||84.6|37.31|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84.6||||84.6|25.08|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84.6||||84.6|37.31|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84.6||||84.6|25.08|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|84.6||||84.6|25.08|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|84.6||||84.6|58.37|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84.6||||84.6|25.08|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|Self-pay|Self-pay|84.6||||84.6|29.61|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|84.6||||84.6|25.08|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84.6||||84.6|25.08|58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84.6||||84.6||58.37|25.08
10057|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE SPINAL W/STYLETTE 18GA X 3 1/2"" DISP"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84.6||||84.6||58.37|25.08
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AARP [1000]|AARP [100000]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AETNA [1015]|AETNA [101529]|38.13||||38.13|16.82|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.13||||38.13|11.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BCBS UTHCT [115568]|38.13||||38.13|17.92|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.13||||38.13|19.07|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.13||||38.13|19.07|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.13||||38.13|24.02|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.13||||38.13|11.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|CIGNA [1260]|CIGNA GWH [126023]|38.13||||38.13|20.97|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|GROUP PENSION ADMIN [1450]|GPA [145000]|38.13||||38.13|26.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|38.13||||38.13|19.07|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.13||||38.13|16.82|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.13||||38.13|11.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.13||||38.13|16.82|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.13||||38.13|11.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|38.13||||38.13|11.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|PHCS [1780]|PHCS MULTIPLAN [178000]|38.13||||38.13|26.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.13||||38.13|11.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|Self-pay|Self-pay|38.13||||38.13|13.35|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|38.13||||38.13|11.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.13||||38.13|11.31|26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.13||||38.13||26.31|11.31
100611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC 1 % TOPICAL GEL|100 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.13||||38.13||26.31|11.31
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|AARP [1000]|AARP [100000]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|AETNA [1015]|AETNA [101529]|84.6||||84.6|37.31|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84.6||||84.6|25.08|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|BCBS [1155]|BCBS UTHCT [115568]|84.6||||84.6|39.76|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84.6||||84.6|42.3|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84.6||||84.6|42.3|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84.6||||84.6|53.3|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84.6||||84.6|25.08|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|CIGNA [1260]|CIGNA GWH [126023]|84.6||||84.6|46.53|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|84.6||||84.6|58.37|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|84.6||||84.6|42.3|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84.6||||84.6|37.31|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84.6||||84.6|25.08|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84.6||||84.6|37.31|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84.6||||84.6|25.08|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|84.6||||84.6|25.08|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|84.6||||84.6|58.37|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84.6||||84.6|25.08|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|Self-pay|Self-pay|84.6||||84.6|29.61|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|84.6||||84.6|25.08|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84.6||||84.6|25.08|58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84.6||||84.6||58.37|25.08
10062|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLOSTOMY BAG DRAINABLE 12"" OPAQUE 2 1/2"" CUTTING SURFACE"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84.6||||84.6||58.37|25.08
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|AARP [1000]|AARP [100000]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|AETNA [1015]|AETNA [101529]|2.9||||2.9|1.28|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.9||||2.9|0.86|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|BCBS [1155]|BCBS UTHCT [115568]|2.9||||2.9|1.36|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.9||||2.9|1.45|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.9||||2.9|1.45|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.9||||2.9|1.83|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.9||||2.9|0.86|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|CIGNA [1260]|CIGNA GWH [126023]|2.9||||2.9|1.6|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2.9||||2.9|2|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.9||||2.9|1.45|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.9||||2.9|1.28|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.9||||2.9|0.86|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.9||||2.9|1.28|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.9||||2.9|0.86|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.9||||2.9|0.86|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2.9||||2.9|2|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.9||||2.9|0.86|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|Self-pay|Self-pay|2.9||||2.9|1.01|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.9||||2.9|0.86|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.9||||2.9|0.86|2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.9||||2.9||2|0.86
10063|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CLAMP FOR HOLLISTER COLOSTOMY POUCHES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.9||||2.9||2|0.86
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.27||||0.27|0.12|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.27||||0.27|0.08|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.27||||0.27|0.13|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.27||||0.27|0.14|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.27||||0.27|0.14|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.27||||0.27|0.17|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.27||||0.27|0.08|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.27||||0.27|0.15|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.27||||0.27|0.19|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.27||||0.27|0.14|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.27||||0.27|0.12|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.27||||0.27|0.08|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.27||||0.27|0.12|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.27||||0.27|0.08|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.27||||0.27|0.08|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.27||||0.27|0.19|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.27||||0.27|0.08|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.27||||0.27|0.09|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.27||||0.27|0.08|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.27||||0.27|0.08|0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.27||||0.27||0.19|0.08
10069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.27||||0.27||0.19|0.08
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.3||||0.3|0.13|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.3||||0.3|0.09|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.3||||0.3|0.14|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.3||||0.3|0.15|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.3||||0.3|0.15|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.3||||0.3|0.19|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.3||||0.3|0.09|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.3||||0.3|0.17|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.3||||0.3|0.21|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.3||||0.3|0.15|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.3||||0.3|0.13|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.3||||0.3|0.09|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.3||||0.3|0.13|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.3||||0.3|0.09|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.3||||0.3|0.09|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.3||||0.3|0.21|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.3||||0.3|0.09|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.3||||0.3|0.1|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.3||||0.3|0.09|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.3||||0.3|0.09|0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.3||||0.3||0.21|0.09
10070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.3||||0.3||0.21|0.09
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|AARP [1000]|AARP [100000]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|AETNA [1015]|AETNA [101529]|12.75||||12.75|5.62|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.75||||12.75|3.78|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|BCBS [1155]|BCBS UTHCT [115568]|12.75||||12.75|5.99|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.75||||12.75|6.37|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.75||||12.75|6.37|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.75||||12.75|8.03|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.75||||12.75|3.78|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|CIGNA [1260]|CIGNA GWH [126023]|12.75||||12.75|7.01|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12.75||||12.75|8.79|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.75||||12.75|6.37|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.75||||12.75|5.62|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.75||||12.75|3.78|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.75||||12.75|5.62|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.75||||12.75|3.78|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.75||||12.75|3.78|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12.75||||12.75|8.79|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.75||||12.75|3.78|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|Self-pay|Self-pay|12.75||||12.75|4.47|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.75||||12.75|3.78|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.75||||12.75|3.78|8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.75||||12.75||8.79|3.78
10092|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT STERILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.75||||12.75||8.79|3.78
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|AARP [1000]|AARP [100000]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|AETNA [1015]|AETNA [101529]|71.2||||71.2|31.4|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.2||||71.2|21.11|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|BCBS [1155]|BCBS UTHCT [115568]|71.2||||71.2|33.46|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.2||||71.2|35.6|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.2||||71.2|35.6|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.2||||71.2|44.86|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.2||||71.2|21.11|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|CIGNA [1260]|CIGNA GWH [126023]|71.2||||71.2|39.16|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71.2||||71.2|49.13|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71.2||||71.2|35.6|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.2||||71.2|31.4|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.2||||71.2|21.11|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.2||||71.2|31.4|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.2||||71.2|21.11|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|71.2||||71.2|21.11|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71.2||||71.2|49.13|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.2||||71.2|21.11|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|Self-pay|Self-pay|71.2||||71.2|24.92|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71.2||||71.2|21.11|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.2||||71.2|21.11|49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.2||||71.2||49.13|21.11
10093|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL PUNCTURE TRAY 20 GA X 3 1/2"" NEEDLE (LUMBAR)"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.2||||71.2||49.13|21.11
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|AARP [1000]|AARP [100000]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|AETNA [1015]|AETNA [101529]|31.56||||31.56|13.92|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.56||||31.56|9.36|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|BCBS [1155]|BCBS UTHCT [115568]|31.56||||31.56|14.83|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.56||||31.56|15.78|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.56||||31.56|15.78|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.56||||31.56|19.88|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.56||||31.56|9.36|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|CIGNA [1260]|CIGNA GWH [126023]|31.56||||31.56|17.36|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31.56||||31.56|21.77|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.56||||31.56|15.78|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.56||||31.56|13.92|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.56||||31.56|9.36|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.56||||31.56|13.92|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.56||||31.56|9.36|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.56||||31.56|9.36|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31.56||||31.56|21.77|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.56||||31.56|9.36|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|Self-pay|Self-pay|31.56||||31.56|11.05|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.56||||31.56|9.36|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.56||||31.56|9.36|21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.56||||31.56||21.77|9.36
10095|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LACERATION TRAY 16/CS. MEDLINE DYNJ03000|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.56||||31.56||21.77|9.36
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|AARP [1000]|AARP [100000]|164.44||||164.44|74|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|164.44||||164.44||113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|AETNA [1015]|AETNA [101529]|164.44||||164.44|72.52|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|164.44||||164.44|48.76|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|164.44||||164.44||113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|164.44||||164.44||113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|BCBS [1155]|BCBS UTHCT [115568]|164.44||||164.44|77.29|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|164.44||||164.44|82.22|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|164.44||||164.44|82.22|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|164.44||||164.44|103.6|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|164.44||||164.44|48.76|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|164.44||||164.44||113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|CIGNA [1260]|CIGNA GWH [126023]|164.44||||164.44|90.44|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|164.44||||164.44|113.46|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|164.44||||164.44|82.22|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|164.44||||164.44||113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|164.44||||164.44|72.52|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|164.44||||164.44|48.76|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|164.44||||164.44||113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|164.44||||164.44|72.52|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|164.44||||164.44|48.76|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|164.44||||164.44|48.76|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|164.44||||164.44|113.46|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|164.44||||164.44|48.76|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|Self-pay|Self-pay|164.44||||164.44|57.55|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|164.44||||164.44|48.76|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|164.44||||164.44|48.76|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|164.44||||164.44|74|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|164.44||||164.44||113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|164.44||||164.44||113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|164.44||||164.44|74|113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|164.44||||164.44||113.46|48.76
10097|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THORACENTESIS TRAY TURKLE SAFETY PROCEDURE TRAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|164.44||||164.44||113.46|48.76
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.18||||7.18|3.17|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.18||||7.18|2.13|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|7.18||||7.18|3.37|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.18||||7.18|3.59|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.18||||7.18|3.59|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.18||||7.18|4.52|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.18||||7.18|2.13|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|7.18||||7.18|3.95|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.18||||7.18|4.95|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.18||||7.18|3.59|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.18||||7.18|3.17|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.18||||7.18|2.13|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.18||||7.18|3.17|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.18||||7.18|2.13|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.18||||7.18|2.13|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.18||||7.18|4.95|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.18||||7.18|2.13|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|Self-pay|Self-pay|7.18||||7.18|2.51|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.18||||7.18|2.13|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.18||||7.18|2.13|4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.18||||7.18||4.95|2.13
100992|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 700 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.18||||7.18||4.95|2.13
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.17||||0.17|0.07|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.17||||0.17|0.05|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.17||||0.17|0.08|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.17||||0.17|0.09|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.17||||0.17|0.09|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.17||||0.17|0.11|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.17||||0.17|0.05|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.17||||0.17|0.09|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.17||||0.17|0.12|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.17||||0.17|0.09|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.17||||0.17|0.07|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.17||||0.17|0.05|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.17||||0.17|0.07|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.17||||0.17|0.05|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.17||||0.17|0.05|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.17||||0.17|0.12|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.17||||0.17|0.05|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|Self-pay|Self-pay|0.17||||0.17|0.06|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.17||||0.17|0.05|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.17||||0.17|0.05|0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.17||||0.17||0.12|0.05
101|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.17||||0.17||0.12|0.05
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|AARP [1000]|AARP [100000]|408.01||||408.01|183.61|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|408.01||||408.01||281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|AETNA [1015]|AETNA [101529]|408.01||||408.01|179.93|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|408.01||||408.01|120.98|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|408.01||||408.01||281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|408.01||||408.01||281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|BCBS [1155]|BCBS UTHCT [115568]|408.01||||408.01|191.77|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|408.01||||408.01|204.01|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|408.01||||408.01|204.01|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|408.01||||408.01|257.05|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|408.01||||408.01|120.98|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|408.01||||408.01||281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|CIGNA [1260]|CIGNA GWH [126023]|408.01||||408.01|224.41|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|408.01||||408.01|281.53|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|408.01||||408.01|204.01|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|408.01||||408.01||281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|408.01||||408.01|179.93|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|408.01||||408.01|120.98|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|408.01||||408.01||281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|408.01||||408.01|179.93|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|408.01||||408.01|120.98|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|408.01||||408.01|120.98|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|408.01||||408.01|281.53|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|408.01||||408.01|120.98|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|Self-pay|Self-pay|408.01||||408.01|142.8|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|408.01||||408.01|120.98|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|408.01||||408.01|120.98|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|408.01||||408.01|183.61|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|408.01||||408.01||281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|408.01||||408.01||281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|408.01||||408.01|183.61|281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|408.01||||408.01||281.53|120.98
10100|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PARACENTESIS TRAY QUICK TAP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|408.01||||408.01||281.53|120.98
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|431.7||||431.7|190.38|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|431.7||||431.7|128|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|431.7||||431.7|202.9|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|431.7||||431.7|0|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|431.7||||431.7|215.85|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|431.7||||431.7|271.97|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|431.7||||431.7|128|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|431.7||||431.7|237.44|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|431.7||||431.7|297.87|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|431.7||||431.7|215.85|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|431.7||||431.7|190.38|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|431.7||||431.7|128|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|431.7||||431.7|190.38|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|431.7||||431.7|128|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|431.7||||431.7|128|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|431.7||||431.7|297.87|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|431.7||||431.7|128|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|Self-pay|Self-pay|431.7||||431.7|151.09|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|431.7||||431.7|128|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|431.7||||431.7|128|297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|431.7||||431.7||297.87|128
101034|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL A CONJ VACC 1 OF 2(PF) 10 MCG/0.5 ML (FINAL) IM SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|431.7||||431.7||297.87|128
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.16||||0.16|0.07|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.16||||0.16|0.05|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.16||||0.16|0.08|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.16||||0.16|0.08|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.16||||0.16|0.08|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.16||||0.16|0.1|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.16||||0.16|0.05|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.16||||0.16|0.09|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.16||||0.16|0.11|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.16||||0.16|0.08|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.16||||0.16|0.07|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.16||||0.16|0.05|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.16||||0.16|0.07|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.16||||0.16|0.05|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.16||||0.16|0.05|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.16||||0.16|0.11|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.16||||0.16|0.05|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.16||||0.16|0.06|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.16||||0.16|0.05|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.16||||0.16|0.05|0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.16||||0.16||0.11|0.05
10117|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.16||||0.16||0.11|0.05
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|AARP [1000]|AARP [100000]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|AETNA [1015]|AETNA [101529]|5.01||||5.01|2.21|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.01||||5.01|1.49|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|BCBS [1155]|BCBS UTHCT [115568]|5.01||||5.01|2.35|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.01||||5.01|2.51|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.01||||5.01|2.51|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.01||||5.01|3.16|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.01||||5.01|1.49|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|CIGNA [1260]|CIGNA GWH [126023]|5.01||||5.01|2.76|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5.01||||5.01|3.46|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.01||||5.01|2.51|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.01||||5.01|2.21|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.01||||5.01|1.49|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.01||||5.01|2.21|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.01||||5.01|1.49|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.01||||5.01|1.49|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5.01||||5.01|3.46|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.01||||5.01|1.49|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|Self-pay|Self-pay|5.01||||5.01|1.75|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.01||||5.01|1.49|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.01||||5.01|1.49|3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.01||||5.01||3.46|1.49
10124|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY 80 MM SMALL ADULT DUAL CHANNEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.01||||5.01||3.46|1.49
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|AARP [1000]|AARP [100000]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|AETNA [1015]|AETNA [101529]|1.67||||1.67|0.74|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.67||||1.67|0.5|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|BCBS [1155]|BCBS UTHCT [115568]|1.67||||1.67|0.78|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.67||||1.67|0.84|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.67||||1.67|0.84|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.67||||1.67|1.05|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.67||||1.67|0.5|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|CIGNA [1260]|CIGNA GWH [126023]|1.67||||1.67|0.92|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1.67||||1.67|1.15|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.67||||1.67|0.84|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.67||||1.67|0.74|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.67||||1.67|0.5|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.67||||1.67|0.74|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.67||||1.67|0.5|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.67||||1.67|0.5|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1.67||||1.67|1.15|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.67||||1.67|0.5|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|Self-pay|Self-pay|1.67||||1.67|0.58|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.67||||1.67|0.5|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.67||||1.67|0.5|1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.67||||1.67||1.15|0.5
10125|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN 90MM DISP. MEDIUM ADULT OPAQUE PLAS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.67||||1.67||1.15|0.5
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.5||||0.5|0.22|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.5||||0.5|0.15|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.5||||0.5|0.24|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.5||||0.5|0.25|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.5||||0.5|0.25|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.5||||0.5|0.32|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.5||||0.5|0.15|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.5||||0.5|0.28|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.5||||0.5|0.35|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.5||||0.5|0.25|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.5||||0.5|0.22|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.5||||0.5|0.15|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.5||||0.5|0.22|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.5||||0.5|0.15|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.5||||0.5|0.15|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.5||||0.5|0.35|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.5||||0.5|0.15|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.5||||0.5|0.17|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.5||||0.5|0.15|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.5||||0.5|0.15|13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.5||||0.5||13.77|0.15
10126|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYBURIDE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.5||||0.5||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|AARP [1000]|AARP [100000]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|AETNA [1015]|AETNA [101529]|19.95||||19.95|8.8|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.95||||19.95|5.92|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|BCBS [1155]|BCBS UTHCT [115568]|19.95||||19.95|9.38|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.95||||19.95|9.98|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.95||||19.95|9.98|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.95||||19.95|12.57|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.95||||19.95|5.92|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|CIGNA [1260]|CIGNA GWH [126023]|19.95||||19.95|10.97|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|19.95||||19.95|13.77|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.95||||19.95|9.98|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.95||||19.95|8.8|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.95||||19.95|5.92|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.95||||19.95|8.8|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.95||||19.95|5.92|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.95||||19.95|5.92|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|19.95||||19.95|13.77|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.95||||19.95|5.92|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|Self-pay|Self-pay|19.95||||19.95|6.98|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.95||||19.95|5.92|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.95||||19.95|5.92|13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.95||||19.95||13.77|0.15
10126|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 7.0 28FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.95||||19.95||13.77|0.15
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|AARP [1000]|AARP [100000]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|AETNA [1015]|AETNA [101529]|4.83||||4.83|2.13|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.83||||4.83|1.43|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|BCBS [1155]|BCBS UTHCT [115568]|4.83||||4.83|2.27|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.83||||4.83|2.42|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.83||||4.83|2.42|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.83||||4.83|3.05|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.83||||4.83|1.43|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|CIGNA [1260]|CIGNA GWH [126023]|4.83||||4.83|2.66|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4.83||||4.83|3.34|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.83||||4.83|2.42|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.83||||4.83|2.13|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.83||||4.83|1.43|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.83||||4.83|2.13|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.83||||4.83|1.43|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.83||||4.83|1.43|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4.83||||4.83|3.34|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.83||||4.83|1.43|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|Self-pay|Self-pay|4.83||||4.83|1.69|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.83||||4.83|1.43|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.83||||4.83|1.43|3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.83||||4.83||3.34|1.43
10127|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY BERMAN LARGE ADULT 100 MM DISP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.83||||4.83||3.34|1.43
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|AARP [1000]|AARP [100000]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|AETNA [1015]|AETNA [101529]|20.04||||20.04|8.84|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.04||||20.04|5.94|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|BCBS [1155]|BCBS UTHCT [115568]|20.04||||20.04|9.42|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.04||||20.04|10.02|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.04||||20.04|10.02|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.04||||20.04|12.63|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.04||||20.04|5.94|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|CIGNA [1260]|CIGNA GWH [126023]|20.04||||20.04|11.02|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20.04||||20.04|13.83|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.04||||20.04|10.02|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.04||||20.04|8.84|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.04||||20.04|5.94|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.04||||20.04|8.84|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.04||||20.04|5.94|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.04||||20.04|5.94|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20.04||||20.04|13.83|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.04||||20.04|5.94|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|Self-pay|Self-pay|20.04||||20.04|7.01|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.04||||20.04|5.94|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.04||||20.04|5.94|13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.04||||20.04||13.83|5.94
10128|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 MURPHY W/CUFF ORAL STERILE 1|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.04||||20.04||13.83|5.94
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|AARP [1000]|AARP [100000]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|AETNA [1015]|AETNA [101529]|14.15||||14.15|6.24|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.15||||14.15|4.2|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|BCBS [1155]|BCBS UTHCT [115568]|14.15||||14.15|6.65|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.15||||14.15|7.08|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.15||||14.15|7.08|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.15||||14.15|8.92|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.15||||14.15|4.2|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|CIGNA [1260]|CIGNA GWH [126023]|14.15||||14.15|7.78|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14.15||||14.15|9.76|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.15||||14.15|7.08|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.15||||14.15|6.24|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.15||||14.15|4.2|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.15||||14.15|6.24|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.15||||14.15|4.2|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.15||||14.15|4.2|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14.15||||14.15|9.76|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.15||||14.15|4.2|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|Self-pay|Self-pay|14.15||||14.15|4.95|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.15||||14.15|4.2|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.15||||14.15|4.2|9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.15||||14.15||9.76|4.2
10129|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 7 1/2 MURPHY W/CUFF ORAL STERI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|AARP [1000]|AARP [100000]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|AETNA [1015]|AETNA [101529]|14.15||||14.15|6.24|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.15||||14.15|4.2|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|BCBS [1155]|BCBS UTHCT [115568]|14.15||||14.15|6.65|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.15||||14.15|7.08|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.15||||14.15|7.08|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.15||||14.15|8.92|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.15||||14.15|4.2|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|CIGNA [1260]|CIGNA GWH [126023]|14.15||||14.15|7.78|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14.15||||14.15|9.76|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.15||||14.15|7.08|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.15||||14.15|6.24|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.15||||14.15|4.2|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.15||||14.15|6.24|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.15||||14.15|4.2|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.15||||14.15|4.2|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14.15||||14.15|9.76|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.15||||14.15|4.2|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|Self-pay|Self-pay|14.15||||14.15|4.95|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.15||||14.15|4.2|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.15||||14.15|4.2|9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.15||||14.15||9.76|4.2
10130|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 MURPHY W/CUFF ORAL STERILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.15||||14.15||9.76|4.2
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|AARP [1000]|AARP [100000]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|AETNA [1015]|AETNA [101529]|205.99||||205.99|90.84|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|205.99||||205.99|61.07|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|BCBS [1155]|BCBS UTHCT [115568]|205.99||||205.99|96.81|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|205.99||||205.99|102.99|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|205.99||||205.99|102.99|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|205.99||||205.99|129.77|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|205.99||||205.99|61.07|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|CIGNA [1260]|CIGNA GWH [126023]|205.99||||205.99|113.29|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|205.99||||205.99|142.13|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|205.99||||205.99|102.99|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|205.99||||205.99|90.84|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|205.99||||205.99|61.07|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|205.99||||205.99|90.84|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|205.99||||205.99|61.07|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|205.99||||205.99|61.07|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|205.99||||205.99|142.13|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|205.99||||205.99|61.07|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|Self-pay|Self-pay|205.99||||205.99|72.1|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|205.99||||205.99|61.07|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|205.99||||205.99|61.07|142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|205.99||||205.99||142.13|61.07
10137|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPECULUM VAGINAL WITH LOCKING MECHANISM SMALL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|205.99||||205.99||142.13|61.07
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|AARP [1000]|AARP [100000]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|AETNA [1015]|AETNA [101529]|98.66||||98.66|43.51|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|98.66||||98.66|29.25|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|BCBS [1155]|BCBS UTHCT [115568]|98.66||||98.66|46.37|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|98.66||||98.66|49.33|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|98.66||||98.66|49.33|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|98.66||||98.66|62.16|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|98.66||||98.66|29.25|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|CIGNA [1260]|CIGNA GWH [126023]|98.66||||98.66|54.26|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|98.66||||98.66|68.08|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|98.66||||98.66|49.33|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|98.66||||98.66|43.51|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|98.66||||98.66|29.25|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|98.66||||98.66|43.51|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|98.66||||98.66|29.25|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|98.66||||98.66|29.25|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|98.66||||98.66|68.08|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|98.66||||98.66|29.25|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|Self-pay|Self-pay|98.66||||98.66|34.53|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|98.66||||98.66|29.25|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|98.66||||98.66|29.25|68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|98.66||||98.66||68.08|29.25
10142|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOEPOST-OP LARGE FITS SIZES: MEN 9-11 CLOSED TOE. DARCO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|98.66||||98.66||68.08|29.25
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|AARP [1000]|AARP [100000]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|AETNA [1015]|AETNA [101529]|84.6||||84.6|37.31|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84.6||||84.6|25.08|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|BCBS [1155]|BCBS UTHCT [115568]|84.6||||84.6|39.76|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84.6||||84.6|42.3|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84.6||||84.6|42.3|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84.6||||84.6|53.3|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84.6||||84.6|25.08|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|CIGNA [1260]|CIGNA GWH [126023]|84.6||||84.6|46.53|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|GROUP PENSION ADMIN [1450]|GPA [145000]|84.6||||84.6|58.37|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|84.6||||84.6|42.3|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84.6||||84.6|37.31|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84.6||||84.6|25.08|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84.6||||84.6|37.31|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84.6||||84.6|25.08|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|84.6||||84.6|25.08|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|PHCS [1780]|PHCS MULTIPLAN [178000]|84.6||||84.6|58.37|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84.6||||84.6|25.08|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|Self-pay|Self-pay|84.6||||84.6|29.61|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|84.6||||84.6|25.08|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84.6||||84.6|25.08|58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84.6||||84.6||58.37|25.08
10143|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP X-LARGE FITS SIZES: MEN 11.5-14 CLOSED TOE.|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84.6||||84.6||58.37|25.08
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|AARP [1000]|AARP [100000]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|AETNA [1015]|AETNA [101529]|77.26||||77.26|34.07|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|77.26||||77.26|22.91|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|BCBS [1155]|BCBS UTHCT [115568]|77.26||||77.26|36.31|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|77.26||||77.26|38.63|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|77.26||||77.26|38.63|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|77.26||||77.26|48.68|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|77.26||||77.26|22.91|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|CIGNA [1260]|CIGNA GWH [126023]|77.26||||77.26|42.5|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|GROUP PENSION ADMIN [1450]|GPA [145000]|77.26||||77.26|53.31|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|77.26||||77.26|38.63|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|77.26||||77.26|34.07|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|77.26||||77.26|22.91|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|77.26||||77.26|34.07|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|77.26||||77.26|22.91|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|77.26||||77.26|22.91|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|PHCS [1780]|PHCS MULTIPLAN [178000]|77.26||||77.26|53.31|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|77.26||||77.26|22.91|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|Self-pay|Self-pay|77.26||||77.26|27.04|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|77.26||||77.26|22.91|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|77.26||||77.26|22.91|53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|77.26||||77.26||53.31|22.91
10144|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S SMALL FITS SIZE'S 4-6 OPEN TOE.|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|77.26||||77.26||53.31|22.91
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|AARP [1000]|AARP [100000]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|AETNA [1015]|AETNA [101529]|74.72||||74.72|32.95|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.72||||74.72|22.15|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|BCBS [1155]|BCBS UTHCT [115568]|74.72||||74.72|35.12|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.72||||74.72|37.36|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.72||||74.72|37.36|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.72||||74.72|47.07|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.72||||74.72|22.15|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|CIGNA [1260]|CIGNA GWH [126023]|74.72||||74.72|41.09|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74.72||||74.72|51.55|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.72||||74.72|37.36|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.72||||74.72|32.95|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.72||||74.72|22.15|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.72||||74.72|32.95|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.72||||74.72|22.15|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.72||||74.72|22.15|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74.72||||74.72|51.55|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.72||||74.72|22.15|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|Self-pay|Self-pay|74.72||||74.72|26.16|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.72||||74.72|22.15|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.72||||74.72|22.15|51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.72||||74.72||51.55|22.15
10145|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S MEDIUM FITS SIZES 6.5-8 OPEN TOE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|AARP [1000]|AARP [100000]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|AETNA [1015]|AETNA [101529]|74.72||||74.72|32.95|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.72||||74.72|22.15|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|BCBS [1155]|BCBS UTHCT [115568]|74.72||||74.72|35.12|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.72||||74.72|37.36|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.72||||74.72|37.36|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.72||||74.72|47.07|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.72||||74.72|22.15|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|CIGNA [1260]|CIGNA GWH [126023]|74.72||||74.72|41.09|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74.72||||74.72|51.55|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.72||||74.72|37.36|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.72||||74.72|32.95|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.72||||74.72|22.15|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.72||||74.72|32.95|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.72||||74.72|22.15|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.72||||74.72|22.15|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74.72||||74.72|51.55|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.72||||74.72|22.15|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|Self-pay|Self-pay|74.72||||74.72|26.16|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.72||||74.72|22.15|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.72||||74.72|22.15|51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.72||||74.72||51.55|22.15
10146|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP WOMEN'S LARGE FITS SIZES 8.5-10. DARCO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.72||||74.72||51.55|22.15
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|AARP [1000]|AARP [100000]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|AETNA [1015]|AETNA [101529]|74.54||||74.54|32.87|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.54||||74.54|22.1|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|BCBS [1155]|BCBS UTHCT [115568]|74.54||||74.54|35.03|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.54||||74.54|37.27|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.54||||74.54|37.27|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.54||||74.54|46.96|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.54||||74.54|22.1|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|CIGNA [1260]|CIGNA GWH [126023]|74.54||||74.54|41|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74.54||||74.54|51.43|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.54||||74.54|37.27|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.54||||74.54|32.87|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.54||||74.54|22.1|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.54||||74.54|32.87|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.54||||74.54|22.1|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.54||||74.54|22.1|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74.54||||74.54|51.43|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.54||||74.54|22.1|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|Self-pay|Self-pay|74.54||||74.54|26.09|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.54||||74.54|22.1|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.54||||74.54|22.1|51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.54||||74.54||51.43|22.1
10147|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S SMALL FITS SIZES 4 - 5 1/2. DARCO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.54||||74.54||51.43|22.1
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|AARP [1000]|AARP [100000]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|AETNA [1015]|AETNA [101529]|74.63||||74.63|32.91|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.63||||74.63|22.13|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|BCBS [1155]|BCBS UTHCT [115568]|74.63||||74.63|35.07|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.63||||74.63|37.31|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.63||||74.63|37.31|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.63||||74.63|47.02|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.63||||74.63|22.13|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|CIGNA [1260]|CIGNA GWH [126023]|74.63||||74.63|41.04|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74.63||||74.63|51.49|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.63||||74.63|37.31|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.63||||74.63|32.91|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.63||||74.63|22.13|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.63||||74.63|32.91|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.63||||74.63|22.13|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.63||||74.63|22.13|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74.63||||74.63|51.49|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.63||||74.63|22.13|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|Self-pay|Self-pay|74.63||||74.63|26.12|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.63||||74.63|22.13|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.63||||74.63|22.13|51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.63||||74.63||51.49|22.13
10148|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S MEDIUM FITS SIZES 6 - 8.5.|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.63||||74.63||51.49|22.13
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.64||||0.64|0.28|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.64||||0.64|0.19|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.64||||0.64|0.3|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.64||||0.64|0.32|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.64||||0.64|0.32|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.64||||0.64|0.4|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.64||||0.64|0.19|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.64||||0.64|0.35|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.64||||0.64|0.44|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.64||||0.64|0.32|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.64||||0.64|0.28|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.64||||0.64|0.19|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.64||||0.64|0.28|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.64||||0.64|0.19|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.64||||0.64|0.19|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.64||||0.64|0.44|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.64||||0.64|0.19|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.64||||0.64|0.22|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.64||||0.64|0.19|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.64||||0.64|0.19|51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.64||||0.64||51.61|0.19
10149|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUANFACINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.64||||0.64||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|AARP [1000]|AARP [100000]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|AETNA [1015]|AETNA [101529]|74.8||||74.8|32.99|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.8||||74.8|22.18|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|BCBS [1155]|BCBS UTHCT [115568]|74.8||||74.8|35.16|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.8||||74.8|37.4|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.8||||74.8|37.4|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.8||||74.8|47.13|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.8||||74.8|22.18|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|CIGNA [1260]|CIGNA GWH [126023]|74.8||||74.8|41.14|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74.8||||74.8|51.61|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.8||||74.8|37.4|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.8||||74.8|32.99|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.8||||74.8|22.18|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.8||||74.8|32.99|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.8||||74.8|22.18|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.8||||74.8|22.18|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74.8||||74.8|51.61|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.8||||74.8|22.18|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|Self-pay|Self-pay|74.8||||74.8|26.18|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.8||||74.8|22.18|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.8||||74.8|22.18|51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.8||||74.8||51.61|0.19
10149|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S LARGE FITS SIZES 9 - 11.5. DARCO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.8||||74.8||51.61|0.19
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|AARP [1000]|AARP [100000]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|AETNA [1015]|AETNA [101529]|74.28||||74.28|32.76|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.28||||74.28|22.02|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|BCBS [1155]|BCBS UTHCT [115568]|74.28||||74.28|34.91|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.28||||74.28|37.14|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.28||||74.28|37.14|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.28||||74.28|46.79|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.28||||74.28|22.02|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|CIGNA [1260]|CIGNA GWH [126023]|74.28||||74.28|40.85|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74.28||||74.28|51.25|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.28||||74.28|37.14|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.28||||74.28|32.76|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.28||||74.28|22.02|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.28||||74.28|32.76|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.28||||74.28|22.02|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.28||||74.28|22.02|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74.28||||74.28|51.25|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.28||||74.28|22.02|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|Self-pay|Self-pay|74.28||||74.28|26|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.28||||74.28|22.02|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.28||||74.28|22.02|51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.28||||74.28||51.25|22.02
10150|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SHOE POST-OP MEN'S X-LARGE FITS SIZE 12+.|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.28||||74.28||51.25|22.02
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|AARP [1000]|AARP [100000]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|AETNA [1015]|AETNA [101529]|10.46||||10.46|4.61|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.46||||10.46|3.1|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|BCBS [1155]|BCBS UTHCT [115568]|10.46||||10.46|4.92|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.46||||10.46|0|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.46||||10.46|5.23|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.46||||10.46|6.59|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.46||||10.46|3.1|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|CIGNA [1260]|CIGNA GWH [126023]|10.46||||10.46|5.75|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|10.46||||10.46|7.22|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.46||||10.46|5.23|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.46||||10.46|4.61|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.46||||10.46|3.1|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.46||||10.46|4.61|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.46||||10.46|3.1|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.46||||10.46|3.1|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|10.46||||10.46|7.22|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.46||||10.46|3.1|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|Self-pay|Self-pay|10.46||||10.46|3.66|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.46||||10.46|3.1|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.46||||10.46|3.1|7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.46||||10.46||7.22|3.1
10154|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING COPA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.46||||10.46||7.22|3.1
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|AARP [1000]|AARP [100000]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|AETNA [1015]|AETNA [101529]|406.86||||406.86|179.43|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|406.86||||406.86|120.63|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|BCBS [1155]|BCBS UTHCT [115568]|406.86||||406.86|191.23|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|406.86||||406.86|203.43|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|406.86||||406.86|203.43|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|406.86||||406.86|256.32|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|406.86||||406.86|120.63|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|CIGNA [1260]|CIGNA GWH [126023]|406.86||||406.86|223.77|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|406.86||||406.86|280.74|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|406.86||||406.86|203.43|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|406.86||||406.86|179.43|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|406.86||||406.86|120.63|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|406.86||||406.86|179.43|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|406.86||||406.86|120.63|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|406.86||||406.86|120.63|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|406.86||||406.86|280.74|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|406.86||||406.86|120.63|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|Self-pay|Self-pay|406.86||||406.86|142.4|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|406.86||||406.86|120.63|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|406.86||||406.86|120.63|280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|406.86||||406.86||280.74|120.63
10155|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURAGLIDE CHEST TUBE INSERTION KIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|406.86||||406.86||280.74|120.63
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|AARP [1000]|AARP [100000]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|AETNA [1015]|AETNA [101529]|76.47||||76.47|33.72|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76.47||||76.47|22.67|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|BCBS [1155]|BCBS UTHCT [115568]|76.47||||76.47|35.94|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76.47||||76.47|38.24|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76.47||||76.47|38.24|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76.47||||76.47|48.18|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76.47||||76.47|22.67|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|CIGNA [1260]|CIGNA GWH [126023]|76.47||||76.47|42.06|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|GROUP PENSION ADMIN [1450]|GPA [145000]|76.47||||76.47|52.77|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|76.47||||76.47|38.24|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76.47||||76.47|33.72|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76.47||||76.47|22.67|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76.47||||76.47|33.72|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76.47||||76.47|22.67|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|76.47||||76.47|22.67|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|PHCS [1780]|PHCS MULTIPLAN [178000]|76.47||||76.47|52.77|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76.47||||76.47|22.67|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|Self-pay|Self-pay|76.47||||76.47|26.76|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|76.47||||76.47|22.67|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76.47||||76.47|22.67|52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76.47||||76.47||52.77|22.67
10158|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLEEVE KNEE MEDIUM.|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76.47||||76.47||52.77|22.67
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AARP [1000]|AARP [100000]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|120.28||||120.28|75.12|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|120.28||||120.28|35.66|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|120.28||||120.28|56.53|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|120.28||||120.28|0|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|120.28||||120.28|60.14|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|120.28||||120.28|75.78|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|120.28||||120.28|35.66|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|120.28||||120.28|66.15|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|120.28||||120.28|82.99|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|120.28||||120.28|17.7|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|120.28||||120.28|75.12|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|120.28||||120.28|35.66|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|120.28||||120.28|75.12|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|120.28||||120.28|35.66|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|120.28||||120.28|35.66|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|120.28||||120.28|82.99|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|120.28||||120.28|35.66|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|Self-pay|Self-pay|120.28||||120.28|42.1|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|120.28||||120.28|35.66|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|120.28||||120.28|35.66|82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|120.28||||120.28||82.99|17.7
10162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL DECANOATE 100 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|120.28||||120.28||82.99|17.7
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|AARP [1000]|AARP [100000]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|AETNA [1015]|AETNA [101529]|33.31||||33.31|14.69|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.31||||33.31|9.88|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|BCBS [1155]|BCBS UTHCT [115568]|33.31||||33.31|15.66|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.31||||33.31|16.66|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.31||||33.31|16.66|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.31||||33.31|20.99|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.31||||33.31|9.88|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|CIGNA [1260]|CIGNA GWH [126023]|33.31||||33.31|18.32|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|33.31||||33.31|22.99|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.31||||33.31|16.66|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.31||||33.31|14.69|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.31||||33.31|9.88|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.31||||33.31|14.69|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.31||||33.31|9.88|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.31||||33.31|9.88|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|33.31||||33.31|22.99|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.31||||33.31|9.88|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|Self-pay|Self-pay|33.31||||33.31|11.66|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.31||||33.31|9.88|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.31||||33.31|9.88|22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.31||||33.31||22.99|9.88
10167|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STATLOCK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.31||||33.31||22.99|9.88
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|AARP [1000]|AARP [100000]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|AETNA [1015]|AETNA [101529]|6.68||||6.68|2.95|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.68||||6.68|1.98|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|BCBS [1155]|BCBS UTHCT [115568]|6.68||||6.68|3.14|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.68||||6.68|3.34|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.68||||6.68|3.34|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.68||||6.68|4.21|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.68||||6.68|1.98|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|CIGNA [1260]|CIGNA GWH [126023]|6.68||||6.68|3.67|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6.68||||6.68|4.61|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.68||||6.68|3.34|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.68||||6.68|2.95|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.68||||6.68|1.98|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.68||||6.68|2.95|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.68||||6.68|1.98|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.68||||6.68|1.98|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6.68||||6.68|4.61|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.68||||6.68|1.98|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|Self-pay|Self-pay|6.68||||6.68|2.34|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.68||||6.68|1.98|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.68||||6.68|1.98|4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.68||||6.68||4.61|1.98
10172|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ENDOSCOPIC MARKER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.68||||6.68||4.61|1.98
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|AARP [1000]|AARP [100000]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|AETNA [1015]|AETNA [101529]|104.72||||104.72|46.18|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104.72||||104.72|31.05|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|BCBS [1155]|BCBS UTHCT [115568]|104.72||||104.72|49.22|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104.72||||104.72|52.36|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104.72||||104.72|52.36|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104.72||||104.72|65.97|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104.72||||104.72|31.05|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|CIGNA [1260]|CIGNA GWH [126023]|104.72||||104.72|57.6|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104.72||||104.72|72.26|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|104.72||||104.72|52.36|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104.72||||104.72|46.18|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104.72||||104.72|31.05|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104.72||||104.72|46.18|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104.72||||104.72|31.05|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|104.72||||104.72|31.05|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104.72||||104.72|72.26|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104.72||||104.72|31.05|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|Self-pay|Self-pay|104.72||||104.72|36.65|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|104.72||||104.72|31.05|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104.72||||104.72|31.05|72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104.72||||104.72||72.26|31.05
10173|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE LARIET|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104.72||||104.72||72.26|31.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|AARP [1000]|AARP [100000]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|AETNA [1015]|AETNA [101529]|54.15||||54.15|23.88|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54.15||||54.15|16.05|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|BCBS [1155]|BCBS UTHCT [115568]|54.15||||54.15|25.45|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54.15||||54.15|27.07|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54.15||||54.15|27.07|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54.15||||54.15|34.11|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54.15||||54.15|16.05|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|CIGNA [1260]|CIGNA GWH [126023]|54.15||||54.15|29.78|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54.15||||54.15|37.36|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54.15||||54.15|27.07|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54.15||||54.15|23.88|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54.15||||54.15|16.05|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54.15||||54.15|23.88|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54.15||||54.15|16.05|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54.15||||54.15|16.05|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54.15||||54.15|37.36|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54.15||||54.15|16.05|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|Self-pay|Self-pay|54.15||||54.15|18.95|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54.15||||54.15|16.05|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54.15||||54.15|16.05|37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54.15||||54.15||37.36|16.05
10174|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BIOPSY RADIAL JAW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54.15||||54.15||37.36|16.05
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|10.36||||10.36|6|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.36||||10.36|3.07|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|10.36||||10.36|4.87|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.36||||10.36|0|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.36||||10.36|5.18|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.36||||10.36|6.53|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.36||||10.36|3.07|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|10.36||||10.36|5.7|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.36||||10.36|7.15|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.36||||10.36|0.4|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.36||||10.36|6|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.36||||10.36|3.07|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.36||||10.36|6|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.36||||10.36|3.07|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.36||||10.36|3.07|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.36||||10.36|7.15|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.36||||10.36|3.07|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|10.36||||10.36|3.63|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.36||||10.36|3.07|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.36||||10.36|3.07|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.36||||10.36||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|21.12||||21.12|18|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.12||||21.12|6.26|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|21.12||||21.12|9.93|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.12||||21.12|0|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.12||||21.12|10.56|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.12||||21.12|13.31|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.12||||21.12|6.26|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|21.12||||21.12|11.62|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.12||||21.12|14.57|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.12||||21.12|0.4|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.12||||21.12|18|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.12||||21.12|6.26|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.12||||21.12|18|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.12||||21.12|6.26|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.12||||21.12|6.26|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.12||||21.12|14.57|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.12||||21.12|6.26|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|Self-pay|Self-pay|21.12||||21.12|7.39|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.12||||21.12|6.26|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.12||||21.12|6.26|18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.12||||21.12||18|0.4
10176|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.12||||21.12||18|0.4
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|AARP [1000]|AARP [100000]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|AETNA [1015]|AETNA [101529]|112.2||||112.2|49.48|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|112.2||||112.2|33.27|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|BCBS [1155]|BCBS UTHCT [115568]|112.2||||112.2|52.73|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|112.2||||112.2|56.1|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|112.2||||112.2|56.1|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|112.2||||112.2|70.69|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|112.2||||112.2|33.27|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|CIGNA [1260]|CIGNA GWH [126023]|112.2||||112.2|61.71|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|112.2||||112.2|77.42|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|112.2||||112.2|56.1|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|112.2||||112.2|49.48|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|112.2||||112.2|33.27|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|112.2||||112.2|49.48|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|112.2||||112.2|33.27|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|112.2||||112.2|33.27|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|112.2||||112.2|77.42|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|112.2||||112.2|33.27|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|Self-pay|Self-pay|112.2||||112.2|39.27|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|112.2||||112.2|33.27|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|112.2||||112.2|33.27|77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|112.2||||112.2||77.42|33.27
10177|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE EXACTO COLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|112.2||||112.2||77.42|33.27
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|AARP [1000]|AARP [100000]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|AETNA [1015]|AETNA [101529]|247.53||||247.53|109.16|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|247.53||||247.53|73.39|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|BCBS [1155]|BCBS UTHCT [115568]|247.53||||247.53|116.34|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|247.53||||247.53|123.77|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|247.53||||247.53|123.77|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|247.53||||247.53|155.94|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|247.53||||247.53|73.39|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|CIGNA [1260]|CIGNA GWH [126023]|247.53||||247.53|136.14|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|GROUP PENSION ADMIN [1450]|GPA [145000]|247.53||||247.53|170.8|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|247.53||||247.53|123.77|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|247.53||||247.53|109.16|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|247.53||||247.53|73.39|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|247.53||||247.53|109.16|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|247.53||||247.53|73.39|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|247.53||||247.53|73.39|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|PHCS [1780]|PHCS MULTIPLAN [178000]|247.53||||247.53|170.8|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|247.53||||247.53|73.39|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|Self-pay|Self-pay|247.53||||247.53|86.64|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|247.53||||247.53|73.39|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|247.53||||247.53|73.39|170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|247.53||||247.53||170.8|73.39
10178|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE CARR LOCK 25G|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|247.53||||247.53||170.8|73.39
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|AARP [1000]|AARP [100000]|605||||605|272.25|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|605||||605||417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|AETNA [1015]|AETNA [101529]|605||||605|266.81|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|605||||605|179.38|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|605||||605||417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|605||||605||417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|BCBS [1155]|BCBS UTHCT [115568]|605||||605|284.35|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|605||||605|302.5|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|605||||605|302.5|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|605||||605|381.15|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|605||||605|179.38|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|605||||605||417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|CIGNA [1260]|CIGNA GWH [126023]|605||||605|332.75|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|605||||605|417.45|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|605||||605|302.5|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|605||||605||417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|605||||605|266.81|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|605||||605|179.38|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|605||||605||417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|605||||605|266.81|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|605||||605|179.38|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|605||||605|179.38|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|605||||605|417.45|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|605||||605|179.38|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|Self-pay|Self-pay|605||||605|211.75|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|605||||605|179.38|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|605||||605|179.38|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|605||||605|272.25|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|605||||605||417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|605||||605||417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|605||||605|272.25|417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|605||||605||417.45|179.38
10179|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE,SAFEGUIDE SPRING TIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|605||||605||417.45|179.38
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|AARP [1000]|AARP [100000]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|AETNA [1015]|AETNA [101529]|19795||||19795|8729.6|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19795||||19795|5869.22|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|BCBS [1155]|BCBS UTHCT [115568]|19795||||19795|9303.65|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19795||||19795|9897.5|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19795||||19795|9897.5|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19795||||19795|12470.85|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19795||||19795|5869.22|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|CIGNA [1260]|CIGNA GWH [126023]|19795||||19795|10887.25|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|19795||||19795|13658.55|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19795||||19795|9897.5|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19795||||19795|8729.6|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19795||||19795|5869.22|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19795||||19795|8729.6|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19795||||19795|5869.22|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|19795||||19795|5869.22|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|19795||||19795|13658.55|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19795||||19795|5869.22|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|Self-pay|Self-pay|19795||||19795|6928.25|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19795||||19795|5869.22|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19795||||19795|5869.22|13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19795||||19795||13658.55|5869.22
10180|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYSCOPE DS II ACC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19795||||19795||13658.55|5869.22
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|8.06||||8.06|3|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.06||||8.06|2.39|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|8.06||||8.06|3.79|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.06||||8.06|0|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.06||||8.06|4.03|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.06||||8.06|5.08|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.06||||8.06|2.39|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|8.06||||8.06|4.43|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.06||||8.06|5.56|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.06||||8.06|0.4|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.06||||8.06|3|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.06||||8.06|2.39|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.06||||8.06|3|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.06||||8.06|2.39|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.06||||8.06|2.39|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.06||||8.06|5.56|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.06||||8.06|2.39|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|8.06||||8.06|2.82|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.06||||8.06|2.39|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.06||||8.06|2.39|2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.06||||8.06||2262.89|0.4
10181|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 5,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.06||||8.06||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|AARP [1000]|AARP [100000]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|AETNA [1015]|AETNA [101529]|3279.55||||3279.55|1446.28|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3279.55||||3279.55|972.39|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|BCBS [1155]|BCBS UTHCT [115568]|3279.55||||3279.55|1541.39|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3279.55||||3279.55|1639.78|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3279.55||||3279.55|1639.78|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3279.55||||3279.55|2066.12|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3279.55||||3279.55|972.39|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|CIGNA [1260]|CIGNA GWH [126023]|3279.55||||3279.55|1803.75|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3279.55||||3279.55|2262.89|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3279.55||||3279.55|1639.78|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3279.55||||3279.55|1446.28|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3279.55||||3279.55|972.39|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3279.55||||3279.55|1446.28|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3279.55||||3279.55|972.39|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3279.55||||3279.55|972.39|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3279.55||||3279.55|2262.89|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3279.55||||3279.55|972.39|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|Self-pay|Self-pay|3279.55||||3279.55|1147.84|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3279.55||||3279.55|972.39|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3279.55||||3279.55|972.39|2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3279.55||||3279.55||2262.89|0.4
10181|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPYBITE BIOPSY FORCEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3279.55||||3279.55||2262.89|0.4
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|AARP [1000]|AARP [100000]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|AETNA [1015]|AETNA [101529]|14156.1||||14156.1|6242.84|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14156.1||||14156.1|4197.28|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|BCBS [1155]|BCBS UTHCT [115568]|14156.1||||14156.1|6653.37|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14156.1||||14156.1|7078.05|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14156.1||||14156.1|7078.05|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14156.1||||14156.1|8918.34|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14156.1||||14156.1|4197.28|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|CIGNA [1260]|CIGNA GWH [126023]|14156.1||||14156.1|7785.86|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14156.1||||14156.1|9767.71|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14156.1||||14156.1|7078.05|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14156.1||||14156.1|6242.84|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14156.1||||14156.1|4197.28|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14156.1||||14156.1|6242.84|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14156.1||||14156.1|4197.28|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|14156.1||||14156.1|4197.28|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14156.1||||14156.1|9767.71|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14156.1||||14156.1|4197.28|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|Self-pay|Self-pay|14156.1||||14156.1|4954.63|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14156.1||||14156.1|4197.28|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14156.1||||14156.1|4197.28|9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14156.1||||14156.1||9767.71|4197.28
10182|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 EXP RFA BALLOON CATH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14156.1||||14156.1||9767.71|4197.28
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AARP [1000]|AARP [100000]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AETNA [1015]|AETNA [101529]|112.2||||112.2|49.48|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|112.2||||112.2|33.27|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS [1155]|BCBS UTHCT [115568]|112.2||||112.2|52.73|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|112.2||||112.2|56.1|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|112.2||||112.2|56.1|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|112.2||||112.2|70.69|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|112.2||||112.2|33.27|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|CIGNA [1260]|CIGNA GWH [126023]|112.2||||112.2|61.71|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|112.2||||112.2|77.42|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|112.2||||112.2|56.1|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|112.2||||112.2|49.48|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|112.2||||112.2|33.27|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|112.2||||112.2|49.48|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|112.2||||112.2|33.27|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|112.2||||112.2|33.27|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|112.2||||112.2|77.42|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|112.2||||112.2|33.27|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|Self-pay|Self-pay|112.2||||112.2|39.27|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|112.2||||112.2|33.27|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|112.2||||112.2|33.27|77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|112.2||||112.2||77.42|33.27
10183|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|112.2||||112.2||77.42|33.27
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AARP [1000]|AARP [100000]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AETNA [1015]|AETNA [101529]|2086.5||||2086.5|920.15|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2086.5||||2086.5|618.65|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS [1155]|BCBS UTHCT [115568]|2086.5||||2086.5|980.66|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2086.5||||2086.5|1043.25|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2086.5||||2086.5|1043.25|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2086.5||||2086.5|1314.5|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2086.5||||2086.5|618.65|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|CIGNA [1260]|CIGNA GWH [126023]|2086.5||||2086.5|1147.58|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2086.5||||2086.5|1439.69|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2086.5||||2086.5|1043.25|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2086.5||||2086.5|920.15|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2086.5||||2086.5|618.65|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2086.5||||2086.5|920.15|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2086.5||||2086.5|618.65|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2086.5||||2086.5|618.65|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2086.5||||2086.5|1439.69|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2086.5||||2086.5|618.65|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|Self-pay|Self-pay|2086.5||||2086.5|730.27|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2086.5||||2086.5|618.65|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2086.5||||2086.5|618.65|1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2086.5||||2086.5||1439.69|618.65
10187|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTURA PRO BIOPSY FORCEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2086.5||||2086.5||1439.69|618.65
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|AARP [1000]|AARP [100000]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|AETNA [1015]|AETNA [101529]|221.97||||221.97|97.89|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|221.97||||221.97|65.82|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|BCBS [1155]|BCBS UTHCT [115568]|221.97||||221.97|104.33|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|221.97||||221.97|110.99|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|221.97||||221.97|110.99|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|221.97||||221.97|139.84|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|221.97||||221.97|65.82|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|CIGNA [1260]|CIGNA GWH [126023]|221.97||||221.97|122.09|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|221.97||||221.97|153.16|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|221.97||||221.97|110.99|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|221.97||||221.97|97.89|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|221.97||||221.97|65.82|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|221.97||||221.97|97.89|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|221.97||||221.97|65.82|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|221.97||||221.97|65.82|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|221.97||||221.97|153.16|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|221.97||||221.97|65.82|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|Self-pay|Self-pay|221.97||||221.97|77.69|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|221.97||||221.97|65.82|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|221.97||||221.97|65.82|153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|221.97||||221.97||153.16|65.82
10190|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR HEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|221.97||||221.97||153.16|65.82
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|AARP [1000]|AARP [100000]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|AETNA [1015]|AETNA [101529]|393.25||||393.25|173.42|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|393.25||||393.25|116.6|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|BCBS [1155]|BCBS UTHCT [115568]|393.25||||393.25|184.83|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|393.25||||393.25|196.63|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|393.25||||393.25|196.63|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|393.25||||393.25|247.75|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|393.25||||393.25|116.6|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|CIGNA [1260]|CIGNA GWH [126023]|393.25||||393.25|216.29|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|393.25||||393.25|271.34|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|393.25||||393.25|196.63|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|393.25||||393.25|173.42|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|393.25||||393.25|116.6|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|393.25||||393.25|173.42|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|393.25||||393.25|116.6|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|393.25||||393.25|116.6|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|393.25||||393.25|271.34|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|393.25||||393.25|116.6|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|Self-pay|Self-pay|393.25||||393.25|137.64|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|393.25||||393.25|116.6|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|393.25||||393.25|116.6|271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|393.25||||393.25||271.34|116.6
10191|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE CAPTIVATOR OVAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|393.25||||393.25||271.34|116.6
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|AARP [1000]|AARP [100000]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|AETNA [1015]|AETNA [101529]|1171.65||||1171.65|516.7|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1171.65||||1171.65|347.39|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|BCBS [1155]|BCBS UTHCT [115568]|1171.65||||1171.65|550.68|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1171.65||||1171.65|585.83|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1171.65||||1171.65|585.83|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1171.65||||1171.65|738.14|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1171.65||||1171.65|347.39|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|CIGNA [1260]|CIGNA GWH [126023]|1171.65||||1171.65|644.41|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1171.65||||1171.65|808.44|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1171.65||||1171.65|585.83|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1171.65||||1171.65|516.7|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1171.65||||1171.65|347.39|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1171.65||||1171.65|516.7|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1171.65||||1171.65|347.39|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1171.65||||1171.65|347.39|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1171.65||||1171.65|808.44|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1171.65||||1171.65|347.39|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|Self-pay|Self-pay|1171.65||||1171.65|410.08|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1171.65||||1171.65|347.39|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1171.65||||1171.65|347.39|808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1171.65||||1171.65||808.44|347.39
10194|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 235CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1171.65||||1171.65||808.44|347.39
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|AARP [1000]|AARP [100000]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|AETNA [1015]|AETNA [101529]|258.03||||258.03|113.79|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258.03||||258.03|76.51|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|BCBS [1155]|BCBS UTHCT [115568]|258.03||||258.03|121.28|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258.03||||258.03|129.02|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258.03||||258.03|129.02|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258.03||||258.03|162.56|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258.03||||258.03|76.51|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|CIGNA [1260]|CIGNA GWH [126023]|258.03||||258.03|141.92|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|258.03||||258.03|178.04|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258.03||||258.03|129.02|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258.03||||258.03|113.79|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258.03||||258.03|76.51|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258.03||||258.03|113.79|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258.03||||258.03|76.51|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|258.03||||258.03|76.51|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|258.03||||258.03|178.04|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258.03||||258.03|76.51|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|Self-pay|Self-pay|258.03||||258.03|90.31|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258.03||||258.03|76.51|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258.03||||258.03|76.51|178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258.03||||258.03||178.04|76.51
10197|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE OVAL CAPTIVATOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258.03||||258.03||178.04|76.51
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|AARP [1000]|AARP [100000]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|AETNA [1015]|AETNA [101529]|84.6||||84.6|37.31|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84.6||||84.6|25.08|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|BCBS [1155]|BCBS UTHCT [115568]|84.6||||84.6|39.76|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84.6||||84.6|42.3|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84.6||||84.6|42.3|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84.6||||84.6|53.3|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84.6||||84.6|25.08|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|CIGNA [1260]|CIGNA GWH [126023]|84.6||||84.6|46.53|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|84.6||||84.6|58.37|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|84.6||||84.6|42.3|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84.6||||84.6|37.31|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84.6||||84.6|25.08|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84.6||||84.6|37.31|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84.6||||84.6|25.08|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|84.6||||84.6|25.08|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|84.6||||84.6|58.37|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84.6||||84.6|25.08|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|Self-pay|Self-pay|84.6||||84.6|29.61|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|84.6||||84.6|25.08|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84.6||||84.6|25.08|58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84.6||||84.6||58.37|25.08
10199|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE POLYP 240CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84.6||||84.6||58.37|25.08
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.12||||0.12|0.05|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.12||||0.12|0.04|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.12||||0.12|0.06|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.12||||0.12|0.06|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.12||||0.12|0.06|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.12||||0.12|0.08|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.12||||0.12|0.04|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.12||||0.12|0.07|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.12||||0.12|0.08|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.12||||0.12|0.06|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.12||||0.12|0.05|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.12||||0.12|0.04|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.12||||0.12|0.05|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.12||||0.12|0.04|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.12||||0.12|0.04|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.12||||0.12|0.08|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.12||||0.12|0.04|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.12||||0.12|0.04|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.12||||0.12|0.04|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.12||||0.12|0.04|0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.12||||0.12||0.08|0.04
102|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.12||||0.12||0.08|0.04
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|AARP [1000]|AARP [100000]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|AETNA [1015]|AETNA [101529]|1305.4||||1305.4|575.68|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1305.4||||1305.4|387.05|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|BCBS [1155]|BCBS UTHCT [115568]|1305.4||||1305.4|613.54|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1305.4||||1305.4|652.7|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1305.4||||1305.4|652.7|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1305.4||||1305.4|822.4|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1305.4||||1305.4|387.05|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|CIGNA [1260]|CIGNA GWH [126023]|1305.4||||1305.4|717.97|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1305.4||||1305.4|900.73|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1305.4||||1305.4|652.7|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1305.4||||1305.4|575.68|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1305.4||||1305.4|387.05|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1305.4||||1305.4|575.68|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1305.4||||1305.4|387.05|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1305.4||||1305.4|387.05|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1305.4||||1305.4|900.73|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1305.4||||1305.4|387.05|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|Self-pay|Self-pay|1305.4||||1305.4|456.89|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1305.4||||1305.4|387.05|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1305.4||||1305.4|387.05|900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1305.4||||1305.4||900.73|387.05
10200|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE MULTI BAND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1305.4||||1305.4||900.73|387.05
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|AARP [1000]|AARP [100000]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|AETNA [1015]|AETNA [101529]|544.5||||544.5|240.12|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|544.5||||544.5|161.44|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|BCBS [1155]|BCBS UTHCT [115568]|544.5||||544.5|255.92|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|544.5||||544.5|272.25|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|544.5||||544.5|272.25|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|544.5||||544.5|343.04|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|544.5||||544.5|161.44|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|CIGNA [1260]|CIGNA GWH [126023]|544.5||||544.5|299.48|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|544.5||||544.5|375.71|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|544.5||||544.5|272.25|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|544.5||||544.5|240.12|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|544.5||||544.5|161.44|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|544.5||||544.5|240.12|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|544.5||||544.5|161.44|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|544.5||||544.5|161.44|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|544.5||||544.5|375.71|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|544.5||||544.5|161.44|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|Self-pay|Self-pay|544.5||||544.5|190.57|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|544.5||||544.5|161.44|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|544.5||||544.5|161.44|375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|544.5||||544.5||375.71|161.44
10201|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NET, POLYP OR FOOD, ROTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|544.5||||544.5||375.71|161.44
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|AARP [1000]|AARP [100000]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|AETNA [1015]|AETNA [101529]|665.5||||665.5|293.49|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|665.5||||665.5|197.32|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|BCBS [1155]|BCBS UTHCT [115568]|665.5||||665.5|312.79|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|665.5||||665.5|332.75|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|665.5||||665.5|332.75|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|665.5||||665.5|419.27|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|665.5||||665.5|197.32|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|CIGNA [1260]|CIGNA GWH [126023]|665.5||||665.5|366.03|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|665.5||||665.5|459.2|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|665.5||||665.5|332.75|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|665.5||||665.5|293.49|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|665.5||||665.5|197.32|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|665.5||||665.5|293.49|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|665.5||||665.5|197.32|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|665.5||||665.5|197.32|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|665.5||||665.5|459.2|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|665.5||||665.5|197.32|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|Self-pay|Self-pay|665.5||||665.5|232.92|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|665.5||||665.5|197.32|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|665.5||||665.5|197.32|459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|665.5||||665.5||459.2|197.32
10202|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GRASPER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|665.5||||665.5||459.2|197.32
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|AARP [1000]|AARP [100000]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|AETNA [1015]|AETNA [101529]|1819||||1819|802.18|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1819||||1819|539.33|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|BCBS [1155]|BCBS UTHCT [115568]|1819||||1819|854.93|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1819||||1819|909.5|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1819||||1819|909.5|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1819||||1819|1145.97|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1819||||1819|539.33|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|CIGNA [1260]|CIGNA GWH [126023]|1819||||1819|1000.45|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1819||||1819|1255.11|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1819||||1819|909.5|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1819||||1819|802.18|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1819||||1819|539.33|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1819||||1819|802.18|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1819||||1819|539.33|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1819||||1819|539.33|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1819||||1819|1255.11|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1819||||1819|539.33|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|Self-pay|Self-pay|1819||||1819|636.65|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1819||||1819|539.33|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1819||||1819|539.33|1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1819||||1819||1255.11|539.33
10206|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE, ECHO-3-22|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1819||||1819||1255.11|539.33
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|AARP [1000]|AARP [100000]|834.9||||834.9|375.71|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|834.9||||834.9||576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|AETNA [1015]|AETNA [101529]|834.9||||834.9|368.19|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|834.9||||834.9|247.55|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|834.9||||834.9||576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|834.9||||834.9||576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|BCBS [1155]|BCBS UTHCT [115568]|834.9||||834.9|392.4|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|834.9||||834.9|417.45|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|834.9||||834.9|417.45|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|834.9||||834.9|525.99|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|834.9||||834.9|247.55|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|834.9||||834.9||576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|CIGNA [1260]|CIGNA GWH [126023]|834.9||||834.9|459.2|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|GROUP PENSION ADMIN [1450]|GPA [145000]|834.9||||834.9|576.08|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|834.9||||834.9|417.45|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|834.9||||834.9||576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|834.9||||834.9|368.19|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|834.9||||834.9|247.55|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|834.9||||834.9||576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|834.9||||834.9|368.19|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|834.9||||834.9|247.55|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|834.9||||834.9|247.55|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|PHCS [1780]|PHCS MULTIPLAN [178000]|834.9||||834.9|576.08|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|834.9||||834.9|247.55|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|Self-pay|Self-pay|834.9||||834.9|292.21|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|834.9||||834.9|247.55|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|834.9||||834.9|247.55|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|834.9||||834.9|375.71|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|834.9||||834.9||576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|834.9||||834.9||576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|834.9||||834.9|375.71|576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|834.9||||834.9||576.08|247.55
10208|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION SHORT WIRE FSW35|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|834.9||||834.9||576.08|247.55
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|AARP [1000]|AARP [100000]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|AETNA [1015]|AETNA [101529]|847||||847|373.53|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|847||||847|251.14|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|BCBS [1155]|BCBS UTHCT [115568]|847||||847|398.09|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|847||||847|423.5|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|847||||847|423.5|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|847||||847|533.61|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|847||||847|251.14|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|CIGNA [1260]|CIGNA GWH [126023]|847||||847|465.85|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|847||||847|584.43|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|847||||847|423.5|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|847||||847|373.53|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|847||||847|251.14|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|847||||847|373.53|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|847||||847|251.14|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|847||||847|251.14|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|847||||847|584.43|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|847||||847|251.14|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|Self-pay|Self-pay|847||||847|296.45|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|847||||847|251.14|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|847||||847|251.14|584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|847||||847||584.43|251.14
10209|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION BALLOON EXTRACTOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|847||||847||584.43|251.14
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|AARP [1000]|AARP [100000]|91.63||||91.63|41.23|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|91.63||||91.63||63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|AETNA [1015]|AETNA [101529]|91.63||||91.63|40.41|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|91.63||||91.63|27.17|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|91.63||||91.63||63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|91.63||||91.63||63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|BCBS [1155]|BCBS UTHCT [115568]|91.63||||91.63|43.07|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|91.63||||91.63|45.82|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|91.63||||91.63|45.82|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|91.63||||91.63|57.73|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|91.63||||91.63|27.17|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|91.63||||91.63||63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|CIGNA [1260]|CIGNA GWH [126023]|91.63||||91.63|50.4|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|91.63||||91.63|63.22|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|91.63||||91.63|45.82|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|91.63||||91.63||63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|91.63||||91.63|40.41|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|91.63||||91.63|27.17|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|91.63||||91.63||63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|91.63||||91.63|40.41|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|91.63||||91.63|27.17|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|91.63||||91.63|27.17|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|91.63||||91.63|63.22|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|91.63||||91.63|27.17|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|Self-pay|Self-pay|91.63||||91.63|32.07|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|91.63||||91.63|27.17|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|91.63||||91.63|27.17|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|91.63||||91.63|41.23|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|91.63||||91.63||63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|91.63||||91.63||63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|91.63||||91.63|41.23|63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|91.63||||91.63||63.22|27.17
10211|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION LOCKING DEVICE FSWLPO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|91.63||||91.63||63.22|27.17
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|AARP [1000]|AARP [100000]|143.9||||143.9|64.76|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|143.9||||143.9||99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|AETNA [1015]|AETNA [101529]|143.9||||143.9|63.46|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|143.9||||143.9|42.67|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|143.9||||143.9||99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|143.9||||143.9||99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|BCBS [1155]|BCBS UTHCT [115568]|143.9||||143.9|67.63|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|143.9||||143.9|71.95|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|143.9||||143.9|71.95|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|143.9||||143.9|90.66|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|143.9||||143.9|42.67|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|143.9||||143.9||99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|CIGNA [1260]|CIGNA GWH [126023]|143.9||||143.9|79.15|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|143.9||||143.9|99.29|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|143.9||||143.9|71.95|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|143.9||||143.9||99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|143.9||||143.9|63.46|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|143.9||||143.9|42.67|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|143.9||||143.9||99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|143.9||||143.9|63.46|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|143.9||||143.9|42.67|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|143.9||||143.9|42.67|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|143.9||||143.9|99.29|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|143.9||||143.9|42.67|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|Self-pay|Self-pay|143.9||||143.9|50.36|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|143.9||||143.9|42.67|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|143.9||||143.9|42.67|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|143.9||||143.9|64.76|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|143.9||||143.9||99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|143.9||||143.9||99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|143.9||||143.9|64.76|99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|143.9||||143.9||99.29|42.67
10212|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL EUS BALLOON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|143.9||||143.9||99.29|42.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|AARP [1000]|AARP [100000]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|AETNA [1015]|AETNA [101529]|1219.8||||1219.8|537.93|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1219.8||||1219.8|361.67|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|BCBS [1155]|BCBS UTHCT [115568]|1219.8||||1219.8|573.31|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1219.8||||1219.8|609.9|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1219.8||||1219.8|609.9|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1219.8||||1219.8|768.47|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1219.8||||1219.8|361.67|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|CIGNA [1260]|CIGNA GWH [126023]|1219.8||||1219.8|670.89|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1219.8||||1219.8|841.66|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1219.8||||1219.8|609.9|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1219.8||||1219.8|537.93|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1219.8||||1219.8|361.67|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1219.8||||1219.8|537.93|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1219.8||||1219.8|361.67|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1219.8||||1219.8|361.67|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1219.8||||1219.8|841.66|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1219.8||||1219.8|361.67|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|Self-pay|Self-pay|1219.8||||1219.8|426.93|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1219.8||||1219.8|361.67|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1219.8||||1219.8|361.67|841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1219.8||||1219.8||841.66|361.67
10214|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 10-11-12|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|AARP [1000]|AARP [100000]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|AETNA [1015]|AETNA [101529]|1219.8||||1219.8|537.93|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1219.8||||1219.8|361.67|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|BCBS [1155]|BCBS UTHCT [115568]|1219.8||||1219.8|573.31|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1219.8||||1219.8|609.9|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1219.8||||1219.8|609.9|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1219.8||||1219.8|768.47|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1219.8||||1219.8|361.67|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|CIGNA [1260]|CIGNA GWH [126023]|1219.8||||1219.8|670.89|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1219.8||||1219.8|841.66|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1219.8||||1219.8|609.9|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1219.8||||1219.8|537.93|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1219.8||||1219.8|361.67|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1219.8||||1219.8|537.93|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1219.8||||1219.8|361.67|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1219.8||||1219.8|361.67|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1219.8||||1219.8|841.66|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1219.8||||1219.8|361.67|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|Self-pay|Self-pay|1219.8||||1219.8|426.93|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1219.8||||1219.8|361.67|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1219.8||||1219.8|361.67|841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1219.8||||1219.8||841.66|361.67
10215|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 12-13.5-15|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1219.8||||1219.8||841.66|361.67
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|AARP [1000]|AARP [100000]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|AETNA [1015]|AETNA [101529]|963||||963|424.68|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|963||||963|285.53|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|BCBS [1155]|BCBS UTHCT [115568]|963||||963|452.61|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|963||||963|481.5|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|963||||963|481.5|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|963||||963|606.69|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|963||||963|285.53|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|CIGNA [1260]|CIGNA GWH [126023]|963||||963|529.65|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|GROUP PENSION ADMIN [1450]|GPA [145000]|963||||963|664.47|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|963||||963|481.5|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|963||||963|424.68|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|963||||963|285.53|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|963||||963|424.68|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|963||||963|285.53|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|963||||963|285.53|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|PHCS [1780]|PHCS MULTIPLAN [178000]|963||||963|664.47|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|963||||963|285.53|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|Self-pay|Self-pay|963||||963|337.05|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|963||||963|285.53|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|963||||963|285.53|664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|963||||963||664.47|285.53
10216|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 15-16.5-18|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|963||||963||664.47|285.53
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|AARP [1000]|AARP [100000]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|AETNA [1015]|AETNA [101529]|1219.8||||1219.8|537.93|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1219.8||||1219.8|361.67|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|BCBS [1155]|BCBS UTHCT [115568]|1219.8||||1219.8|573.31|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1219.8||||1219.8|609.9|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1219.8||||1219.8|609.9|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1219.8||||1219.8|768.47|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1219.8||||1219.8|361.67|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|CIGNA [1260]|CIGNA GWH [126023]|1219.8||||1219.8|670.89|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1219.8||||1219.8|841.66|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1219.8||||1219.8|609.9|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1219.8||||1219.8|537.93|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1219.8||||1219.8|361.67|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1219.8||||1219.8|537.93|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1219.8||||1219.8|361.67|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1219.8||||1219.8|361.67|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1219.8||||1219.8|841.66|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1219.8||||1219.8|361.67|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|Self-pay|Self-pay|1219.8||||1219.8|426.93|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1219.8||||1219.8|361.67|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1219.8||||1219.8|361.67|841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1219.8||||1219.8||841.66|361.67
10217|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HERCULES 18-19-20|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1219.8||||1219.8||841.66|361.67
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|AARP [1000]|AARP [100000]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|AETNA [1015]|AETNA [101529]|65.93||||65.93|29.07|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65.93||||65.93|19.55|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|BCBS [1155]|BCBS UTHCT [115568]|65.93||||65.93|30.98|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65.93||||65.93|32.96|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65.93||||65.93|32.96|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65.93||||65.93|41.53|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65.93||||65.93|19.55|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|CIGNA [1260]|CIGNA GWH [126023]|65.93||||65.93|36.26|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|65.93||||65.93|45.49|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65.93||||65.93|32.96|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65.93||||65.93|29.07|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65.93||||65.93|19.55|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65.93||||65.93|29.07|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65.93||||65.93|19.55|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|65.93||||65.93|19.55|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|65.93||||65.93|45.49|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65.93||||65.93|19.55|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|Self-pay|Self-pay|65.93||||65.93|23.08|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65.93||||65.93|19.55|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65.93||||65.93|19.55|45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65.93||||65.93||45.49|19.55
10218|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP, BIOPSY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65.93||||65.93||45.49|19.55
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|AARP [1000]|AARP [100000]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|AETNA [1015]|AETNA [101529]|1819||||1819|802.18|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1819||||1819|539.33|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|BCBS [1155]|BCBS UTHCT [115568]|1819||||1819|854.93|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1819||||1819|909.5|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1819||||1819|909.5|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1819||||1819|1145.97|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1819||||1819|539.33|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|CIGNA [1260]|CIGNA GWH [126023]|1819||||1819|1000.45|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1819||||1819|1255.11|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1819||||1819|909.5|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1819||||1819|802.18|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1819||||1819|539.33|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1819||||1819|802.18|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1819||||1819|539.33|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1819||||1819|539.33|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1819||||1819|1255.11|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1819||||1819|539.33|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|Self-pay|Self-pay|1819||||1819|636.65|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1819||||1819|539.33|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1819||||1819|539.33|1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1819||||1819||1255.11|539.33
10219|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEEDLE ECHO 25 GA EUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1819||||1819||1255.11|539.33
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|AARP [1000]|AARP [100000]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|AETNA [1015]|AETNA [101529]|780.45||||780.45|344.18|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780.45||||780.45|231.4|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|BCBS [1155]|BCBS UTHCT [115568]|780.45||||780.45|366.81|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780.45||||780.45|390.23|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780.45||||780.45|390.23|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780.45||||780.45|491.68|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780.45||||780.45|231.4|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|CIGNA [1260]|CIGNA GWH [126023]|780.45||||780.45|429.25|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780.45||||780.45|538.51|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780.45||||780.45|366.81|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780.45||||780.45|344.18|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780.45||||780.45|231.4|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780.45||||780.45|344.18|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780.45||||780.45|231.4|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780.45||||780.45|231.4|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780.45||||780.45|538.51|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780.45||||780.45|231.4|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|Self-pay|Self-pay|780.45||||780.45|273.16|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780.45||||780.45|231.4|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780.45||||780.45|231.4|538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780.45||||780.45||538.51|231.4
10220|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-7|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|AARP [1000]|AARP [100000]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|AETNA [1015]|AETNA [101529]|780.45||||780.45|344.18|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780.45||||780.45|231.4|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|BCBS [1155]|BCBS UTHCT [115568]|780.45||||780.45|366.81|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780.45||||780.45|390.23|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780.45||||780.45|390.23|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780.45||||780.45|491.68|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780.45||||780.45|231.4|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|CIGNA [1260]|CIGNA GWH [126023]|780.45||||780.45|429.25|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780.45||||780.45|538.51|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780.45||||780.45|366.81|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780.45||||780.45|344.18|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780.45||||780.45|231.4|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780.45||||780.45|344.18|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780.45||||780.45|231.4|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780.45||||780.45|231.4|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780.45||||780.45|538.51|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780.45||||780.45|231.4|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|Self-pay|Self-pay|780.45||||780.45|273.16|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780.45||||780.45|231.4|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780.45||||780.45|231.4|538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780.45||||780.45||538.51|231.4
10221|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|STENT, CLSO 10-9|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780.45||||780.45||538.51|231.4
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|AARP [1000]|AARP [100000]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|AETNA [1015]|AETNA [101529]|185.05||||185.05|81.61|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|185.05||||185.05|54.87|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|BCBS [1155]|BCBS UTHCT [115568]|185.05||||185.05|86.97|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|185.05||||185.05|92.52|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|185.05||||185.05|92.52|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|185.05||||185.05|116.58|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|185.05||||185.05|54.87|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|CIGNA [1260]|CIGNA GWH [126023]|185.05||||185.05|101.77|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|185.05||||185.05|127.68|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|185.05||||185.05|92.52|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|185.05||||185.05|81.61|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|185.05||||185.05|54.87|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|185.05||||185.05|81.61|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|185.05||||185.05|54.87|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|185.05||||185.05|54.87|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|185.05||||185.05|127.68|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|185.05||||185.05|54.87|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|Self-pay|Self-pay|185.05||||185.05|64.77|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|185.05||||185.05|54.87|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|185.05||||185.05|54.87|127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|185.05||||185.05||127.68|54.87
10222|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEP THERAPY SYSTEM DEVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|185.05||||185.05||127.68|54.87
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.05||||6.05|2.67|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.05||||6.05|1.79|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|6.05||||6.05|2.84|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.05||||6.05|3.03|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.05||||6.05|3.03|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.05||||6.05|3.81|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.05||||6.05|1.79|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|6.05||||6.05|3.33|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.05||||6.05|4.17|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.05||||6.05|3.03|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.05||||6.05|2.67|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.05||||6.05|1.79|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.05||||6.05|2.67|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.05||||6.05|1.79|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.05||||6.05|1.79|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.05||||6.05|4.17|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.05||||6.05|1.79|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|Self-pay|Self-pay|6.05||||6.05|2.12|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.05||||6.05|1.79|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.05||||6.05|1.79|4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.05||||6.05||4.17|1.79
10235|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYCHLOROQUINE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.05||||6.05||4.17|1.79
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.86||||2.86|1.26|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.86||||2.86|0.85|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|2.86||||2.86|1.34|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.86||||2.86|1.43|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.86||||2.86|1.43|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.86||||2.86|1.8|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.86||||2.86|0.85|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|2.86||||2.86|1.57|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.86||||2.86|1.97|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.86||||2.86|1.43|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.86||||2.86|1.26|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.86||||2.86|0.85|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.86||||2.86|1.26|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.86||||2.86|0.85|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.86||||2.86|0.85|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.86||||2.86|1.97|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.86||||2.86|0.85|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.86||||2.86|1|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.86||||2.86|0.85|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.86||||2.86|0.85|1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.86||||2.86||1421.23|0.85
10236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYUREA 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.86||||2.86||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|AARP [1000]|AARP [100000]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|AETNA [1015]|AETNA [101529]|2059.75||||2059.75|908.35|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2059.75||||2059.75|610.72|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|BCBS [1155]|BCBS UTHCT [115568]|2059.75||||2059.75|968.08|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2059.75||||2059.75|1029.88|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2059.75||||2059.75|1029.88|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2059.75||||2059.75|1297.64|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2059.75||||2059.75|610.72|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|CIGNA [1260]|CIGNA GWH [126023]|2059.75||||2059.75|1132.86|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2059.75||||2059.75|1421.23|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2059.75||||2059.75|1029.88|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2059.75||||2059.75|908.35|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2059.75||||2059.75|610.72|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2059.75||||2059.75|908.35|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2059.75||||2059.75|610.72|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2059.75||||2059.75|610.72|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2059.75||||2059.75|1421.23|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2059.75||||2059.75|610.72|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|Self-pay|Self-pay|2059.75||||2059.75|720.91|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2059.75||||2059.75|610.72|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2059.75||||2059.75|610.72|1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2059.75||||2059.75||1421.23|0.85
10236|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|METANEB CIRCUIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2059.75||||2059.75||1421.23|0.85
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|AARP [1000]|AARP [100000]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|AETNA [1015]|AETNA [101529]|1310.75||||1310.75|578.04|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1310.75||||1310.75|388.64|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|BCBS [1155]|BCBS UTHCT [115568]|1310.75||||1310.75|616.05|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1310.75||||1310.75|655.38|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1310.75||||1310.75|655.38|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1310.75||||1310.75|825.77|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1310.75||||1310.75|388.64|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|CIGNA [1260]|CIGNA GWH [126023]|1310.75||||1310.75|720.91|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1310.75||||1310.75|904.42|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1310.75||||1310.75|655.38|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1310.75||||1310.75|578.04|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1310.75||||1310.75|388.64|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1310.75||||1310.75|578.04|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1310.75||||1310.75|388.64|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1310.75||||1310.75|388.64|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1310.75||||1310.75|904.42|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1310.75||||1310.75|388.64|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|Self-pay|Self-pay|1310.75||||1310.75|458.76|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1310.75||||1310.75|388.64|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1310.75||||1310.75|388.64|904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1310.75||||1310.75||904.42|388.64
10239|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|NEBULIZER BAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1310.75||||1310.75||904.42|388.64
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|AARP [1000]|AARP [100000]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|AETNA [1015]|AETNA [101529]|12.75||||12.75|5.62|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.75||||12.75|3.78|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|BCBS [1155]|BCBS UTHCT [115568]|12.75||||12.75|5.99|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.75||||12.75|6.37|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.75||||12.75|6.37|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.75||||12.75|8.03|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.75||||12.75|3.78|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|CIGNA [1260]|CIGNA GWH [126023]|12.75||||12.75|7.01|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12.75||||12.75|8.79|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.75||||12.75|6.37|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.75||||12.75|5.62|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.75||||12.75|3.78|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.75||||12.75|5.62|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.75||||12.75|3.78|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.75||||12.75|3.78|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12.75||||12.75|8.79|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.75||||12.75|3.78|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|Self-pay|Self-pay|12.75||||12.75|4.47|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.75||||12.75|3.78|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.75||||12.75|3.78|8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.75||||12.75||8.79|3.78
10244|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUTURE REMOVAL KIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.75||||12.75||8.79|3.78
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|AARP [1000]|AARP [100000]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|AETNA [1015]|AETNA [101529]|12.65||||12.65|5.58|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.65||||12.65|3.75|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|BCBS [1155]|BCBS UTHCT [115568]|12.65||||12.65|5.95|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.65||||12.65|6.33|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.65||||12.65|6.33|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.65||||12.65|7.97|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.65||||12.65|3.75|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|CIGNA [1260]|CIGNA GWH [126023]|12.65||||12.65|6.96|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.65||||12.65|8.73|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.65||||12.65|6.33|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.65||||12.65|5.58|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.65||||12.65|3.75|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.65||||12.65|5.58|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.65||||12.65|3.75|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.65||||12.65|3.75|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.65||||12.65|8.73|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.65||||12.65|3.75|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|Self-pay|Self-pay|12.65||||12.65|4.43|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.65||||12.65|3.75|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.65||||12.65|3.75|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|120 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.65||||12.65||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|2.27||||2.27|1|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.27||||2.27|0.67|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|2.27||||2.27|1.07|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.27||||2.27|1.14|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.27||||2.27|1.14|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.27||||2.27|1.43|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.27||||2.27|0.67|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|2.27||||2.27|1.25|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.27||||2.27|1.57|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.27||||2.27|1.14|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.27||||2.27|1|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.27||||2.27|0.67|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.27||||2.27|1|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.27||||2.27|0.67|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.27||||2.27|0.67|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.27||||2.27|1.57|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.27||||2.27|0.67|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|2.27||||2.27|0.79|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.27||||2.27|0.67|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.27||||2.27|0.67|8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.27||||2.27||8.73|0.67
10246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 100 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.27||||2.27||8.73|0.67
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|AARP [1000]|AARP [100000]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|AETNA [1015]|AETNA [101529]|13.27||||13.27|5.85|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.27||||13.27|3.94|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|BCBS [1155]|BCBS UTHCT [115568]|13.27||||13.27|6.24|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.27||||13.27|6.64|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.27||||13.27|6.64|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.27||||13.27|8.36|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.27||||13.27|3.94|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|CIGNA [1260]|CIGNA GWH [126023]|13.27||||13.27|7.3|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13.27||||13.27|9.16|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.27||||13.27|6.64|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.27||||13.27|5.85|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.27||||13.27|3.94|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.27||||13.27|5.85|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.27||||13.27|3.94|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.27||||13.27|3.94|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13.27||||13.27|9.16|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.27||||13.27|3.94|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|Self-pay|Self-pay|13.27||||13.27|4.64|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.27||||13.27|3.94|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.27||||13.27|3.94|9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.27||||13.27||9.16|3.94
10248|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER; IV SHIELDED,22 GA X1|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.27||||13.27||9.16|3.94
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|AARP [1000]|AARP [100000]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|AETNA [1015]|AETNA [101529]|23.47||||23.47|10.35|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.47||||23.47|6.96|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|BCBS [1155]|BCBS UTHCT [115568]|23.47||||23.47|11.03|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.47||||23.47|11.73|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.47||||23.47|11.73|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.47||||23.47|14.79|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.47||||23.47|6.96|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|CIGNA [1260]|CIGNA GWH [126023]|23.47||||23.47|12.91|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23.47||||23.47|16.19|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.47||||23.47|11.73|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.47||||23.47|10.35|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.47||||23.47|6.96|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.47||||23.47|10.35|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.47||||23.47|6.96|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.47||||23.47|6.96|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23.47||||23.47|16.19|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.47||||23.47|6.96|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|Self-pay|Self-pay|23.47||||23.47|8.21|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.47||||23.47|6.96|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.47||||23.47|6.96|16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.47||||23.47||16.19|6.96
10258|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"EXTENSION LINE, 12"" MONITORING"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.47||||23.47||16.19|6.96
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|584.11||||584.11|257.59|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|584.11||||584.11|173.19|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|584.11||||584.11|274.53|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|584.11||||584.11|292.06|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|584.11||||584.11|292.06|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|584.11||||584.11|367.99|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|584.11||||584.11|173.19|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|584.11||||584.11|321.26|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|584.11||||584.11|403.04|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|584.11||||584.11|292.06|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|584.11||||584.11|257.59|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|584.11||||584.11|173.19|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|584.11||||584.11|257.59|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|584.11||||584.11|173.19|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|584.11||||584.11|173.19|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|584.11||||584.11|403.04|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|584.11||||584.11|173.19|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|Self-pay|Self-pay|584.11||||584.11|204.44|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|584.11||||584.11|173.19|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|584.11||||584.11|173.19|403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|584.11||||584.11||403.04|173.19
10265|ERX|0250 - PHARMACY-GENERAL|INDIGOTINDISULFONATE SODIUM 8 MG/ML (0.8 %) INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|584.11||||584.11||403.04|173.19
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|AARP [1000]|AARP [100000]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|AETNA [1015]|AETNA [101529]|359.37||||359.37|158.48|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|359.37||||359.37|106.55|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|BCBS [1155]|BCBS UTHCT [115568]|359.37||||359.37|168.9|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|359.37||||359.37|179.69|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|359.37||||359.37|179.69|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|359.37||||359.37|226.4|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|359.37||||359.37|106.55|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|CIGNA [1260]|CIGNA GWH [126023]|359.37||||359.37|197.65|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|359.37||||359.37|247.97|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|359.37||||359.37|179.69|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|359.37||||359.37|158.48|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|359.37||||359.37|106.55|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|359.37||||359.37|158.48|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|359.37||||359.37|106.55|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|359.37||||359.37|106.55|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|359.37||||359.37|247.97|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|359.37||||359.37|106.55|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|Self-pay|Self-pay|359.37||||359.37|125.78|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|359.37||||359.37|106.55|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|359.37||||359.37|106.55|247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|359.37||||359.37||247.97|106.55
10266|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,SINGLE SENSOR 7FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|359.37||||359.37||247.97|106.55
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|AARP [1000]|AARP [100000]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|AETNA [1015]|AETNA [101529]|321.6||||321.6|141.83|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|321.6||||321.6|95.35|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|BCBS [1155]|BCBS UTHCT [115568]|321.6||||321.6|151.15|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|321.6||||321.6|160.8|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|321.6||||321.6|160.8|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|321.6||||321.6|202.61|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|321.6||||321.6|95.35|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|CIGNA [1260]|CIGNA GWH [126023]|321.6||||321.6|176.88|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|321.6||||321.6|221.9|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|321.6||||321.6|160.8|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|321.6||||321.6|141.83|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|321.6||||321.6|95.35|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|321.6||||321.6|141.83|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|321.6||||321.6|95.35|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|321.6||||321.6|95.35|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|321.6||||321.6|221.9|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|321.6||||321.6|95.35|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|Self-pay|Self-pay|321.6||||321.6|112.56|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|321.6||||321.6|95.35|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|321.6||||321.6|95.35|221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|321.6||||321.6||221.9|95.35
10267|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER,TDOC,ABD 7FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|321.6||||321.6||221.9|95.35
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|AARP [1000]|AARP [100000]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|AETNA [1015]|AETNA [101529]|147.18||||147.18|64.91|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|147.18||||147.18|43.64|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|BCBS [1155]|BCBS UTHCT [115568]|147.18||||147.18|69.17|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|147.18||||147.18|73.59|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|147.18||||147.18|73.59|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|147.18||||147.18|92.72|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|147.18||||147.18|43.64|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|CIGNA [1260]|CIGNA GWH [126023]|147.18||||147.18|80.95|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|GROUP PENSION ADMIN [1450]|GPA [145000]|147.18||||147.18|101.55|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|147.18||||147.18|73.59|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|147.18||||147.18|64.91|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|147.18||||147.18|43.64|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|147.18||||147.18|64.91|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|147.18||||147.18|43.64|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|147.18||||147.18|43.64|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|PHCS [1780]|PHCS MULTIPLAN [178000]|147.18||||147.18|101.55|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|147.18||||147.18|43.64|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|Self-pay|Self-pay|147.18||||147.18|51.51|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|147.18||||147.18|43.64|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|147.18||||147.18|43.64|101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|147.18||||147.18||101.55|43.64
10269|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROSTATE BIOPSY NEEDLE 18GA/20|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|147.18||||147.18||101.55|43.64
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|AARP [1000]|AARP [100000]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|AETNA [1015]|AETNA [101529]|20.74||||20.74|9.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.74||||20.74|6.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|BCBS [1155]|BCBS UTHCT [115568]|20.74||||20.74|9.75|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.74||||20.74|10.37|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.74||||20.74|10.37|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.74||||20.74|13.07|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.74||||20.74|6.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|CIGNA [1260]|CIGNA GWH [126023]|20.74||||20.74|11.41|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20.74||||20.74|14.31|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.74||||20.74|10.37|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.74||||20.74|9.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.74||||20.74|6.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.74||||20.74|9.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.74||||20.74|6.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.74||||20.74|6.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20.74||||20.74|14.31|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.74||||20.74|6.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|Self-pay|Self-pay|20.74||||20.74|7.26|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.74||||20.74|6.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.74||||20.74|6.15|14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.74||||20.74||14.31|6.15
10272|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, URETHRAL 16 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.74||||20.74||14.31|6.15
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AARP [1000]|AARP [100000]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AETNA [1015]|AETNA [101529]|460.97||||460.97|398.4|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|460.97||||460.97|136.68|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|460.97||||460.97|216.66|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|460.97||||460.97|0|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|460.97||||460.97|230.49|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|460.97||||460.97|290.41|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|460.97||||460.97|136.68|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|460.97||||460.97|253.53|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|460.97||||460.97|318.07|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|460.97||||460.97|230.49|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|460.97||||460.97|398.4|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|460.97||||460.97|136.68|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|460.97||||460.97|398.4|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|460.97||||460.97|136.68|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|460.97||||460.97|136.68|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|460.97||||460.97|318.07|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|460.97||||460.97|136.68|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|Self-pay|Self-pay|460.97||||460.97|161.34|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|460.97||||460.97|136.68|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|460.97||||460.97|136.68|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|460.97||||460.97||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AARP [1000]|AARP [100000]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AETNA [1015]|AETNA [101529]|138.3||||138.3|119.52|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138.3||||138.3|41.01|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BCBS UTHCT [115568]|138.3||||138.3|65|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138.3||||138.3|0|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138.3||||138.3|69.15|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138.3||||138.3|87.13|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138.3||||138.3|41.01|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|CIGNA [1260]|CIGNA GWH [126023]|138.3||||138.3|76.07|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|138.3||||138.3|95.43|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138.3||||138.3|69.15|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138.3||||138.3|119.52|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138.3||||138.3|41.01|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138.3||||138.3|119.52|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138.3||||138.3|41.01|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|138.3||||138.3|41.01|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|138.3||||138.3|95.43|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138.3||||138.3|41.01|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|Self-pay|Self-pay|138.3||||138.3|48.4|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138.3||||138.3|41.01|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138.3||||138.3|41.01|398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138.3||||138.3||398.4|41.01
10284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN NPH ISOPHANE U-100 HUMAN 100 UNIT/ML SUBCUTANEOUS SUSPENSION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AARP [1000]|AARP [100000]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AETNA [1015]|AETNA [101529]|426.87||||426.87|398.4|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|426.87||||426.87|126.57|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BCBS UTHCT [115568]|426.87||||426.87|200.63|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|426.87||||426.87|0|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|426.87||||426.87|213.44|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|426.87||||426.87|268.93|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|426.87||||426.87|126.57|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|CIGNA [1260]|CIGNA GWH [126023]|426.87||||426.87|234.78|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|426.87||||426.87|294.54|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|426.87||||426.87|213.44|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|426.87||||426.87|398.4|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|426.87||||426.87|126.57|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|426.87||||426.87|398.4|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|426.87||||426.87|126.57|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|426.87||||426.87|126.57|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|426.87||||426.87|294.54|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|426.87||||426.87|126.57|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|Self-pay|Self-pay|426.87||||426.87|149.4|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|426.87||||426.87|126.57|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|426.87||||426.87|126.57|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|426.87||||426.87||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AARP [1000]|AARP [100000]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AETNA [1015]|AETNA [101529]|138.3||||138.3|119.52|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138.3||||138.3|41.01|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BCBS UTHCT [115568]|138.3||||138.3|65|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138.3||||138.3|0|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138.3||||138.3|69.15|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138.3||||138.3|87.13|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138.3||||138.3|41.01|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|CIGNA [1260]|CIGNA GWH [126023]|138.3||||138.3|76.07|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|138.3||||138.3|95.43|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138.3||||138.3|69.15|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138.3||||138.3|119.52|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138.3||||138.3|41.01|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138.3||||138.3|119.52|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138.3||||138.3|41.01|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|138.3||||138.3|41.01|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|138.3||||138.3|95.43|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138.3||||138.3|41.01|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|Self-pay|Self-pay|138.3||||138.3|48.4|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138.3||||138.3|41.01|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138.3||||138.3|41.01|398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138.3||||138.3||398.4|41.01
10286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN HUMAN U-100 NPH-REGULR 70-30 MIX 100 UNIT/ML SUBCUTANEOUS SUSP|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|460.97||||460.97|398.4|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|460.97||||460.97|136.68|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|460.97||||460.97|216.66|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|460.97||||460.97|0|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|460.97||||460.97|230.49|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|460.97||||460.97|290.41|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|460.97||||460.97|136.68|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|460.97||||460.97|253.53|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|460.97||||460.97|318.07|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|460.97||||460.97|230.49|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|460.97||||460.97|398.4|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|460.97||||460.97|136.68|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|460.97||||460.97|398.4|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|460.97||||460.97|136.68|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|460.97||||460.97|136.68|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|460.97||||460.97|318.07|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|460.97||||460.97|136.68|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|460.97||||460.97|161.34|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|460.97||||460.97|136.68|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|460.97||||460.97|136.68|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|460.97||||460.97||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AARP [1000]|AARP [100000]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|138.3||||138.3|119.52|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138.3||||138.3|41.01|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BCBS UTHCT [115568]|138.3||||138.3|65|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138.3||||138.3|0|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138.3||||138.3|69.15|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138.3||||138.3|87.13|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138.3||||138.3|41.01|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|CIGNA [1260]|CIGNA GWH [126023]|138.3||||138.3|76.07|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|138.3||||138.3|95.43|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138.3||||138.3|69.15|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138.3||||138.3|119.52|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138.3||||138.3|41.01|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138.3||||138.3|119.52|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138.3||||138.3|41.01|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|138.3||||138.3|41.01|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|138.3||||138.3|95.43|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138.3||||138.3|41.01|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|Self-pay|Self-pay|138.3||||138.3|48.4|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138.3||||138.3|41.01|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138.3||||138.3|41.01|398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138.3||||138.3||398.4|41.01
10289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN U-100 REGULAR HUMAN 100 UNIT/ML INJECTION SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138.3||||138.3||398.4|41.01
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|0.96||||0.96|0.42|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.96||||0.96|0.28|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|0.96||||0.96|0.45|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.96||||0.96|0.48|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.96||||0.96|0.48|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.96||||0.96|0.6|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.96||||0.96|0.28|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|0.96||||0.96|0.53|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|0.96||||0.96|0.66|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.96||||0.96|0.48|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.96||||0.96|0.42|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.96||||0.96|0.28|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.96||||0.96|0.42|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.96||||0.96|0.28|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.96||||0.96|0.28|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|0.96||||0.96|0.66|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.96||||0.96|0.28|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|0.96||||0.96|0.34|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.96||||0.96|0.28|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.96||||0.96|0.28|0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.96||||0.96||0.66|0.28
103|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.96||||0.96||0.66|0.28
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|AARP [1000]|AARP [100000]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|AETNA [1015]|AETNA [101529]|56.87||||56.87|25.08|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56.87||||56.87|16.86|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|BCBS [1155]|BCBS UTHCT [115568]|56.87||||56.87|26.73|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56.87||||56.87|28.44|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56.87||||56.87|28.44|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56.87||||56.87|35.83|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56.87||||56.87|16.86|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|CIGNA [1260]|CIGNA GWH [126023]|56.87||||56.87|31.28|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|GROUP PENSION ADMIN [1450]|GPA [145000]|56.87||||56.87|39.24|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|56.87||||56.87|28.44|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56.87||||56.87|25.08|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56.87||||56.87|16.86|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56.87||||56.87|25.08|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|56.87||||56.87|16.86|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|56.87||||56.87|16.86|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|PHCS [1780]|PHCS MULTIPLAN [178000]|56.87||||56.87|39.24|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56.87||||56.87|16.86|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|Self-pay|Self-pay|56.87||||56.87|19.9|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|56.87||||56.87|16.86|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56.87||||56.87|16.86|39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56.87||||56.87||39.24|16.86
10300|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLOOD COMPONENT RECIPIENT SET|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|56.87||||56.87||39.24|16.86
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|AARP [1000]|AARP [100000]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|AETNA [1015]|AETNA [101529]|23.29||||23.29|10.27|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.29||||23.29|6.91|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|BCBS [1155]|BCBS UTHCT [115568]|23.29||||23.29|10.95|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.29||||23.29|11.65|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.29||||23.29|11.65|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.29||||23.29|14.67|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.29||||23.29|6.91|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|CIGNA [1260]|CIGNA GWH [126023]|23.29||||23.29|12.81|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23.29||||23.29|16.07|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.29||||23.29|11.65|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.29||||23.29|10.27|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.29||||23.29|6.91|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.29||||23.29|10.27|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.29||||23.29|6.91|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.29||||23.29|6.91|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23.29||||23.29|16.07|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.29||||23.29|6.91|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|Self-pay|Self-pay|23.29||||23.29|8.15|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.29||||23.29|6.91|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.29||||23.29|6.91|16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.29||||23.29||16.07|6.91
10302|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 14 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|AARP [1000]|AARP [100000]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|AETNA [1015]|AETNA [101529]|23.29||||23.29|10.27|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.29||||23.29|6.91|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|BCBS [1155]|BCBS UTHCT [115568]|23.29||||23.29|10.95|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.29||||23.29|11.65|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.29||||23.29|11.65|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.29||||23.29|14.67|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.29||||23.29|6.91|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|CIGNA [1260]|CIGNA GWH [126023]|23.29||||23.29|12.81|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23.29||||23.29|16.07|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.29||||23.29|11.65|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.29||||23.29|10.27|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.29||||23.29|6.91|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.29||||23.29|10.27|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.29||||23.29|6.91|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.29||||23.29|6.91|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23.29||||23.29|16.07|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.29||||23.29|6.91|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|Self-pay|Self-pay|23.29||||23.29|8.15|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.29||||23.29|6.91|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.29||||23.29|6.91|16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.29||||23.29||16.07|6.91
10303|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMPWITH ANTI-REFLUX VALVE 16 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|AARP [1000]|AARP [100000]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|AETNA [1015]|AETNA [101529]|23.29||||23.29|10.27|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.29||||23.29|6.91|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|BCBS [1155]|BCBS UTHCT [115568]|23.29||||23.29|10.95|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.29||||23.29|11.65|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.29||||23.29|11.65|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.29||||23.29|14.67|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.29||||23.29|6.91|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|CIGNA [1260]|CIGNA GWH [126023]|23.29||||23.29|12.81|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23.29||||23.29|16.07|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.29||||23.29|11.65|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.29||||23.29|10.27|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.29||||23.29|6.91|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.29||||23.29|10.27|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.29||||23.29|6.91|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.29||||23.29|6.91|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23.29||||23.29|16.07|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.29||||23.29|6.91|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|Self-pay|Self-pay|23.29||||23.29|8.15|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.29||||23.29|6.91|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.29||||23.29|6.91|16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.29||||23.29||16.07|6.91
10304|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE SALEM SUMP WITH ANTI-REFLUX VALVE 18 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.29||||23.29||16.07|6.91
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|AARP [1000]|AARP [100000]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|AETNA [1015]|AETNA [101529]|7.47||||7.47|3.29|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.47||||7.47|2.22|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|BCBS [1155]|BCBS UTHCT [115568]|7.47||||7.47|3.51|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.47||||7.47|3.74|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.47||||7.47|3.74|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.47||||7.47|4.71|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.47||||7.47|2.22|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|CIGNA [1260]|CIGNA GWH [126023]|7.47||||7.47|4.11|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7.47||||7.47|5.16|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.47||||7.47|3.74|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.47||||7.47|3.29|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.47||||7.47|2.22|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.47||||7.47|3.29|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.47||||7.47|2.22|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.47||||7.47|2.22|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7.47||||7.47|5.16|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.47||||7.47|2.22|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|Self-pay|Self-pay|7.47||||7.47|2.61|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.47||||7.47|2.22|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.47||||7.47|2.22|5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.47||||7.47||5.16|2.22
10306|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE SALEM SUMP SIZE 12 FR 48"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.47||||7.47||5.16|2.22
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|AARP [1000]|AARP [100000]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|AETNA [1015]|AETNA [101529]|5.1||||5.1|2.25|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.1||||5.1|1.51|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|BCBS [1155]|BCBS UTHCT [115568]|5.1||||5.1|2.4|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.1||||5.1|2.55|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.1||||5.1|2.55|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.1||||5.1|3.21|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.1||||5.1|1.51|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|CIGNA [1260]|CIGNA GWH [126023]|5.1||||5.1|2.8|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5.1||||5.1|3.52|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.1||||5.1|2.55|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.1||||5.1|2.25|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.1||||5.1|1.51|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.1||||5.1|2.25|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.1||||5.1|1.51|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.1||||5.1|1.51|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5.1||||5.1|3.52|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.1||||5.1|1.51|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|Self-pay|Self-pay|5.1||||5.1|1.79|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.1||||5.1|1.51|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.1||||5.1|1.51|3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.1||||5.1||3.52|1.51
10307|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"TUBE FEEDING 8FR 16"" STERILE"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.1||||5.1||3.52|1.51
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|AARP [1000]|AARP [100000]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|AETNA [1015]|AETNA [101529]|129.03||||129.03|56.9|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129.03||||129.03|38.26|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|BCBS [1155]|BCBS UTHCT [115568]|129.03||||129.03|60.64|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129.03||||129.03|64.52|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129.03||||129.03|64.52|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129.03||||129.03|81.29|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129.03||||129.03|38.26|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|CIGNA [1260]|CIGNA GWH [126023]|129.03||||129.03|70.97|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|129.03||||129.03|89.03|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|129.03||||129.03|64.52|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129.03||||129.03|56.9|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129.03||||129.03|38.26|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129.03||||129.03|56.9|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129.03||||129.03|38.26|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|129.03||||129.03|38.26|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|129.03||||129.03|89.03|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129.03||||129.03|38.26|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|Self-pay|Self-pay|129.03||||129.03|45.16|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|129.03||||129.03|38.26|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129.03||||129.03|38.26|89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129.03||||129.03||89.03|38.26
10318|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RESUSCITATION BAG ADULT BVM AIR FLOW W/MASK O2 BAG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129.03||||129.03||89.03|38.26
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|303.18||||303.18|136.43|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|303.18||||303.18||209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|303.18||||303.18|0|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|303.18||||303.18|89.89|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|303.18||||303.18||209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|303.18||||303.18||209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|303.18||||303.18|142.49|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|303.18||||303.18|0|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|303.18||||303.18|151.59|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|303.18||||303.18|191|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|303.18||||303.18|89.89|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|303.18||||303.18||209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|303.18||||303.18|166.75|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|303.18||||303.18|209.19|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|303.18||||303.18|0.14|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|303.18||||303.18||209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|303.18||||303.18|0|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|303.18||||303.18|89.89|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|303.18||||303.18||209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|303.18||||303.18|0|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|303.18||||303.18|89.89|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|303.18||||303.18|89.89|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|303.18||||303.18|209.19|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|303.18||||303.18|89.89|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|303.18||||303.18|106.11|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|303.18||||303.18|89.89|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|303.18||||303.18|89.89|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|303.18||||303.18|136.43|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|303.18||||303.18||209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|303.18||||303.18||209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|303.18||||303.18|136.43|209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|303.18||||303.18||209.19|0.14
10328|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOPAMIDOL 76 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|303.18||||303.18||209.19|0.14
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|AARP [1000]|AARP [100000]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|AETNA [1015]|AETNA [101529]|74.4||||74.4|0|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.4||||74.4|22.06|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|BCBS [1155]|BCBS UTHCT [115568]|74.4||||74.4|34.97|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.4||||74.4|0|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.4||||74.4|37.2|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.4||||74.4|46.87|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.4||||74.4|22.06|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|CIGNA [1260]|CIGNA GWH [126023]|74.4||||74.4|40.92|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|74.4||||74.4|51.34|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.4||||74.4|0.09|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.4||||74.4|0|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.4||||74.4|22.06|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.4||||74.4|0|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.4||||74.4|22.06|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.4||||74.4|22.06|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|74.4||||74.4|51.34|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.4||||74.4|22.06|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|Self-pay|Self-pay|74.4||||74.4|26.04|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.4||||74.4|22.06|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.4||||74.4|22.06|69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.4||||74.4||69.11|0.09
10330|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.4||||74.4||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|AARP [1000]|AARP [100000]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|AETNA [1015]|AETNA [101529]|100.16||||100.16|44.17|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|100.16||||100.16|29.7|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|BCBS [1155]|BCBS UTHCT [115568]|100.16||||100.16|47.07|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|100.16||||100.16|50.08|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|100.16||||100.16|50.08|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|100.16||||100.16|63.1|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|100.16||||100.16|29.7|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|CIGNA [1260]|CIGNA GWH [126023]|100.16||||100.16|55.09|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|GROUP PENSION ADMIN [1450]|GPA [145000]|100.16||||100.16|69.11|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|100.16||||100.16|50.08|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|100.16||||100.16|44.17|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|100.16||||100.16|29.7|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|100.16||||100.16|44.17|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|100.16||||100.16|29.7|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|100.16||||100.16|29.7|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|PHCS [1780]|PHCS MULTIPLAN [178000]|100.16||||100.16|69.11|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|100.16||||100.16|29.7|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|Self-pay|Self-pay|100.16||||100.16|35.06|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|100.16||||100.16|29.7|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|100.16||||100.16|29.7|69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|100.16||||100.16||69.11|0.09
10330|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HOTLINE FLUID WARMING SET 30/CASE. SIMS LEVEL 1 #L-70|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|100.16||||100.16||69.11|0.09
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|AARP [1000]|AARP [100000]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|AETNA [1015]|AETNA [101529]|39.03||||39.03|17.21|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.03||||39.03|11.57|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|BCBS [1155]|BCBS UTHCT [115568]|39.03||||39.03|18.34|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.03||||39.03|19.51|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.03||||39.03|19.51|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.03||||39.03|24.59|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.03||||39.03|11.57|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|CIGNA [1260]|CIGNA GWH [126023]|39.03||||39.03|21.47|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|GROUP PENSION ADMIN [1450]|GPA [145000]|39.03||||39.03|26.93|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|39.03||||39.03|19.51|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.03||||39.03|17.21|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.03||||39.03|11.57|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.03||||39.03|17.21|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.03||||39.03|11.57|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|39.03||||39.03|11.57|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|PHCS [1780]|PHCS MULTIPLAN [178000]|39.03||||39.03|26.93|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.03||||39.03|11.57|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|Self-pay|Self-pay|39.03||||39.03|13.66|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|39.03||||39.03|11.57|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.03||||39.03|11.57|26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.03||||39.03||26.93|11.57
10335|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BLANKET WARMING ADULT FULL BODY 85 X 37|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.03||||39.03||26.93|11.57
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|AARP [1000]|AARP [100000]|2.2||||2.2|0.99|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.2||||2.2||1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|AETNA [1015]|AETNA [101529]|2.2||||2.2|0.97|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.2||||2.2|0.65|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.2||||2.2||1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.2||||2.2||1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|BCBS [1155]|BCBS UTHCT [115568]|2.2||||2.2|1.03|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.2||||2.2|0|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.2||||2.2|1.1|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.2||||2.2|1.38|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.2||||2.2|0.65|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.2||||2.2||1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|CIGNA [1260]|CIGNA GWH [126023]|2.2||||2.2|1.21|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2.2||||2.2|1.52|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.2||||2.2|1.1|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.2||||2.2||1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.2||||2.2|0.97|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.2||||2.2|0.65|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.2||||2.2||1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.2||||2.2|0.97|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.2||||2.2|0.65|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.2||||2.2|0.65|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2.2||||2.2|1.52|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.2||||2.2|0.65|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|Self-pay|Self-pay|2.2||||2.2|0.77|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.2||||2.2|0.65|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.2||||2.2|0.65|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.2||||2.2|0.99|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.2||||2.2||1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.2||||2.2||1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.2||||2.2|0.99|1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.2||||2.2||1.52|0.65
10336|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|NASAL CANNULA ADULT 7 FT OVER THE EAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.2||||2.2||1.52|0.65
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|AARP [1000]|AARP [100000]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|AETNA [1015]|AETNA [101529]|75.86||||75.86|33.45|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.86||||75.86|22.49|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|BCBS [1155]|BCBS UTHCT [115568]|75.86||||75.86|35.65|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75.86||||75.86|37.93|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.86||||75.86|37.93|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75.86||||75.86|47.79|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75.86||||75.86|22.49|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|CIGNA [1260]|CIGNA GWH [126023]|75.86||||75.86|41.72|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|75.86||||75.86|52.34|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|75.86||||75.86|37.93|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.86||||75.86|33.45|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.86||||75.86|22.49|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.86||||75.86|33.45|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75.86||||75.86|22.49|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|75.86||||75.86|22.49|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|75.86||||75.86|52.34|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.86||||75.86|22.49|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|Self-pay|Self-pay|75.86||||75.86|26.55|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|75.86||||75.86|22.49|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75.86||||75.86|22.49|52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.86||||75.86||52.34|22.49
10339|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"IMMOBILIZER KNEE UNIVERSAL 20"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75.86||||75.86||52.34|22.49
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|AARP [1000]|AARP [100000]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|AETNA [1015]|AETNA [101529]|68.21||||68.21|30.08|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|68.21||||68.21|20.22|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|BCBS [1155]|BCBS UTHCT [115568]|68.21||||68.21|32.06|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|68.21||||68.21|34.11|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|68.21||||68.21|34.11|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|68.21||||68.21|42.97|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|68.21||||68.21|20.22|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|CIGNA [1260]|CIGNA GWH [126023]|68.21||||68.21|37.52|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|68.21||||68.21|47.07|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|68.21||||68.21|34.11|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|68.21||||68.21|30.08|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|68.21||||68.21|20.22|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|68.21||||68.21|30.08|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|68.21||||68.21|20.22|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|68.21||||68.21|20.22|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|68.21||||68.21|47.07|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|68.21||||68.21|20.22|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|Self-pay|Self-pay|68.21||||68.21|23.87|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|68.21||||68.21|20.22|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|68.21||||68.21|20.22|47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|68.21||||68.21||47.07|20.22
10340|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|IMMOBILIZER ARM/SHOULDER UNIVERSAL SIZE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|68.21||||68.21||47.07|20.22
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AARP [1000]|AARP [100000]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AETNA [1015]|AETNA [101529]|22.06||||22.06|9.73|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.06||||22.06|6.54|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS [1155]|BCBS UTHCT [115568]|22.06||||22.06|10.37|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.06||||22.06|11.03|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.06||||22.06|11.03|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.06||||22.06|13.9|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.06||||22.06|6.54|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|CIGNA [1260]|CIGNA GWH [126023]|22.06||||22.06|12.13|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|22.06||||22.06|15.22|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22.06||||22.06|11.03|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.06||||22.06|9.73|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.06||||22.06|6.54|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.06||||22.06|9.73|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.06||||22.06|6.54|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|22.06||||22.06|6.54|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|22.06||||22.06|15.22|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.06||||22.06|6.54|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|Self-pay|Self-pay|22.06||||22.06|7.72|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22.06||||22.06|6.54|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.06||||22.06|6.54|15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.06||||22.06||15.22|6.54
10342|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.06||||22.06||15.22|6.54
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AARP [1000]|AARP [100000]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AETNA [1015]|AETNA [101529]|18.46||||18.46|8.14|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.46||||18.46|5.47|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS [1155]|BCBS UTHCT [115568]|18.46||||18.46|8.68|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.46||||18.46|9.23|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.46||||18.46|9.23|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.46||||18.46|11.63|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.46||||18.46|5.47|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|CIGNA [1260]|CIGNA GWH [126023]|18.46||||18.46|10.15|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|18.46||||18.46|12.74|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.46||||18.46|9.23|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.46||||18.46|8.14|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.46||||18.46|5.47|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.46||||18.46|8.14|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.46||||18.46|5.47|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.46||||18.46|5.47|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|18.46||||18.46|12.74|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.46||||18.46|5.47|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|Self-pay|Self-pay|18.46||||18.46|6.46|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.46||||18.46|5.47|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.46||||18.46|5.47|12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.46||||18.46||12.74|5.47
10343|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES DOUBLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|AARP [1000]|AARP [100000]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|AETNA [1015]|AETNA [101529]|18.46||||18.46|8.14|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.46||||18.46|5.47|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|BCBS [1155]|BCBS UTHCT [115568]|18.46||||18.46|8.68|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.46||||18.46|9.23|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.46||||18.46|9.23|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.46||||18.46|11.63|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.46||||18.46|5.47|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|CIGNA [1260]|CIGNA GWH [126023]|18.46||||18.46|10.15|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|18.46||||18.46|12.74|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.46||||18.46|9.23|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.46||||18.46|8.14|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.46||||18.46|5.47|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.46||||18.46|8.14|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.46||||18.46|5.47|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.46||||18.46|5.47|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|18.46||||18.46|12.74|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.46||||18.46|5.47|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|Self-pay|Self-pay|18.46||||18.46|6.46|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.46||||18.46|5.47|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.46||||18.46|5.47|12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.46||||18.46||12.74|5.47
10344|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.46||||18.46||12.74|5.47
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|AARP [1000]|AARP [100000]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|AETNA [1015]|AETNA [101529]|50.02||||50.02|22.06|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.02||||50.02|14.83|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|BCBS [1155]|BCBS UTHCT [115568]|50.02||||50.02|23.51|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.02||||50.02|25.01|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.02||||50.02|25.01|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.02||||50.02|31.51|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.02||||50.02|14.83|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|CIGNA [1260]|CIGNA GWH [126023]|50.02||||50.02|27.51|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|50.02||||50.02|34.51|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50.02||||50.02|25.01|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.02||||50.02|22.06|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.02||||50.02|14.83|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.02||||50.02|22.06|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.02||||50.02|14.83|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|50.02||||50.02|14.83|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|50.02||||50.02|34.51|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.02||||50.02|14.83|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|Self-pay|Self-pay|50.02||||50.02|17.51|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50.02||||50.02|14.83|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.02||||50.02|14.83|34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.02||||50.02||34.51|14.83
10345|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER RIB SURGICAL 12"" 45-52"" 4 PANEL"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.02||||50.02||34.51|14.83
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|AARP [1000]|AARP [100000]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|AETNA [1015]|AETNA [101529]|65.57||||65.57|28.92|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65.57||||65.57|19.44|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|BCBS [1155]|BCBS UTHCT [115568]|65.57||||65.57|30.82|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65.57||||65.57|32.79|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65.57||||65.57|32.79|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65.57||||65.57|41.31|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65.57||||65.57|19.44|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|CIGNA [1260]|CIGNA GWH [126023]|65.57||||65.57|36.07|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|65.57||||65.57|45.25|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65.57||||65.57|32.79|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65.57||||65.57|28.92|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65.57||||65.57|19.44|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65.57||||65.57|28.92|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65.57||||65.57|19.44|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|65.57||||65.57|19.44|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|65.57||||65.57|45.25|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65.57||||65.57|19.44|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|Self-pay|Self-pay|65.57||||65.57|22.95|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65.57||||65.57|19.44|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65.57||||65.57|19.44|45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65.57||||65.57||45.25|19.44
10346|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"BINDER ABDOMINAL 12""H 72 - 84"" 4 PANEL"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65.57||||65.57||45.25|19.44
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|AARP [1000]|AARP [100000]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|AETNA [1015]|AETNA [101529]|23.29||||23.29|10.27|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.29||||23.29|6.91|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|BCBS [1155]|BCBS UTHCT [115568]|23.29||||23.29|10.95|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.29||||23.29|11.65|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.29||||23.29|11.65|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.29||||23.29|14.67|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.29||||23.29|6.91|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|CIGNA [1260]|CIGNA GWH [126023]|23.29||||23.29|12.81|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23.29||||23.29|16.07|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.29||||23.29|11.65|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.29||||23.29|10.27|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.29||||23.29|6.91|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.29||||23.29|10.27|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.29||||23.29|6.91|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.29||||23.29|6.91|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23.29||||23.29|16.07|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.29||||23.29|6.91|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|Self-pay|Self-pay|23.29||||23.29|8.15|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.29||||23.29|6.91|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.29||||23.29|6.91|16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.29||||23.29||16.07|6.91
10347|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE SMALL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.29||||23.29||16.07|6.91
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|AARP [1000]|AARP [100000]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|AETNA [1015]|AETNA [101529]|33.4||||33.4|14.73|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.4||||33.4|9.9|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|BCBS [1155]|BCBS UTHCT [115568]|33.4||||33.4|15.7|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.4||||33.4|16.7|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.4||||33.4|16.7|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.4||||33.4|21.04|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.4||||33.4|9.9|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|CIGNA [1260]|CIGNA GWH [126023]|33.4||||33.4|18.37|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|33.4||||33.4|23.05|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.4||||33.4|16.7|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.4||||33.4|14.73|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.4||||33.4|9.9|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.4||||33.4|14.73|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.4||||33.4|9.9|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.4||||33.4|9.9|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|33.4||||33.4|23.05|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.4||||33.4|9.9|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|Self-pay|Self-pay|33.4||||33.4|11.69|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.4||||33.4|9.9|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.4||||33.4|9.9|23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.4||||33.4||23.05|9.9
10348|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE MEDIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.4||||33.4||23.05|9.9
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|AARP [1000]|AARP [100000]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|AETNA [1015]|AETNA [101529]|23.29||||23.29|10.27|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.29||||23.29|6.91|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|BCBS [1155]|BCBS UTHCT [115568]|23.29||||23.29|10.95|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.29||||23.29|11.65|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.29||||23.29|11.65|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.29||||23.29|14.67|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.29||||23.29|6.91|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|CIGNA [1260]|CIGNA GWH [126023]|23.29||||23.29|12.81|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23.29||||23.29|16.07|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.29||||23.29|11.65|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.29||||23.29|10.27|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.29||||23.29|6.91|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.29||||23.29|10.27|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.29||||23.29|6.91|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.29||||23.29|6.91|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23.29||||23.29|16.07|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.29||||23.29|6.91|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|Self-pay|Self-pay|23.29||||23.29|8.15|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.29||||23.29|6.91|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.29||||23.29|6.91|16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.29||||23.29||16.07|6.91
10349|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR LARGE CONTOURED FOAM VELCRO CLOSURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.29||||23.29||16.07|6.91
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|AARP [1000]|AARP [100000]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|AETNA [1015]|AETNA [101529]|41.66||||41.66|18.37|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.66||||41.66|12.35|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|BCBS [1155]|BCBS UTHCT [115568]|41.66||||41.66|19.58|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.66||||41.66|20.83|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.66||||41.66|20.83|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.66||||41.66|26.25|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.66||||41.66|12.35|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|CIGNA [1260]|CIGNA GWH [126023]|41.66||||41.66|22.92|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.66||||41.66|28.75|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.66||||41.66|20.83|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.66||||41.66|18.37|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.66||||41.66|12.35|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.66||||41.66|18.37|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.66||||41.66|12.35|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.66||||41.66|12.35|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.66||||41.66|28.75|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.66||||41.66|12.35|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|Self-pay|Self-pay|41.66||||41.66|14.58|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.66||||41.66|12.35|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.66||||41.66|12.35|28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.66||||41.66||28.75|12.35
10350|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-SM RIGHT 4 1/2-|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|AARP [1000]|AARP [100000]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|AETNA [1015]|AETNA [101529]|41.66||||41.66|18.37|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.66||||41.66|12.35|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|BCBS [1155]|BCBS UTHCT [115568]|41.66||||41.66|19.58|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.66||||41.66|20.83|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.66||||41.66|20.83|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.66||||41.66|26.25|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.66||||41.66|12.35|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|CIGNA [1260]|CIGNA GWH [126023]|41.66||||41.66|22.92|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.66||||41.66|28.75|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.66||||41.66|20.83|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.66||||41.66|18.37|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.66||||41.66|12.35|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.66||||41.66|18.37|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.66||||41.66|12.35|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.66||||41.66|12.35|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.66||||41.66|28.75|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.66||||41.66|12.35|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|Self-pay|Self-pay|41.66||||41.66|14.58|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.66||||41.66|12.35|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.66||||41.66|12.35|28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.66||||41.66||28.75|12.35
10351|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM X-SM LEFT 41/2-51/2"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|AARP [1000]|AARP [100000]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|AETNA [1015]|AETNA [101529]|41.66||||41.66|18.37|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.66||||41.66|12.35|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|BCBS [1155]|BCBS UTHCT [115568]|41.66||||41.66|19.58|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.66||||41.66|20.83|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.66||||41.66|20.83|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.66||||41.66|26.25|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.66||||41.66|12.35|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|CIGNA [1260]|CIGNA GWH [126023]|41.66||||41.66|22.92|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.66||||41.66|28.75|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.66||||41.66|20.83|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.66||||41.66|18.37|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.66||||41.66|12.35|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.66||||41.66|18.37|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.66||||41.66|12.35|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.66||||41.66|12.35|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.66||||41.66|28.75|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.66||||41.66|12.35|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|Self-pay|Self-pay|41.66||||41.66|14.58|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.66||||41.66|12.35|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.66||||41.66|12.35|28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.66||||41.66||28.75|12.35
10352|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT SMALL RIGHT LONG ELASTIC FREEDOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|AARP [1000]|AARP [100000]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|AETNA [1015]|AETNA [101529]|41.66||||41.66|18.37|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.66||||41.66|12.35|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|BCBS [1155]|BCBS UTHCT [115568]|41.66||||41.66|19.58|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.66||||41.66|20.83|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.66||||41.66|20.83|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.66||||41.66|26.25|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.66||||41.66|12.35|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|CIGNA [1260]|CIGNA GWH [126023]|41.66||||41.66|22.92|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.66||||41.66|28.75|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.66||||41.66|20.83|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.66||||41.66|18.37|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.66||||41.66|12.35|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.66||||41.66|18.37|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.66||||41.66|12.35|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.66||||41.66|12.35|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.66||||41.66|28.75|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.66||||41.66|12.35|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|Self-pay|Self-pay|41.66||||41.66|14.58|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.66||||41.66|12.35|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.66||||41.66|12.35|28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.66||||41.66||28.75|12.35
10353|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM RIGHT LONG ELASTIC FREEDOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|AARP [1000]|AARP [100000]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|AETNA [1015]|AETNA [101529]|41.66||||41.66|18.37|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.66||||41.66|12.35|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|BCBS [1155]|BCBS UTHCT [115568]|41.66||||41.66|19.58|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.66||||41.66|20.83|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.66||||41.66|20.83|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.66||||41.66|26.25|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.66||||41.66|12.35|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|CIGNA [1260]|CIGNA GWH [126023]|41.66||||41.66|22.92|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.66||||41.66|28.75|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.66||||41.66|20.83|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.66||||41.66|18.37|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.66||||41.66|12.35|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.66||||41.66|18.37|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.66||||41.66|12.35|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.66||||41.66|12.35|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.66||||41.66|28.75|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.66||||41.66|12.35|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|Self-pay|Self-pay|41.66||||41.66|14.58|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.66||||41.66|12.35|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.66||||41.66|12.35|28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.66||||41.66||28.75|12.35
10354|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT MEDIUM LEFT LONG ELASTIC FREEDOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|AARP [1000]|AARP [100000]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|AETNA [1015]|AETNA [101529]|41.66||||41.66|18.37|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.66||||41.66|12.35|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|BCBS [1155]|BCBS UTHCT [115568]|41.66||||41.66|19.58|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.66||||41.66|20.83|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.66||||41.66|20.83|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.66||||41.66|26.25|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.66||||41.66|12.35|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|CIGNA [1260]|CIGNA GWH [126023]|41.66||||41.66|22.92|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.66||||41.66|28.75|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.66||||41.66|20.83|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.66||||41.66|18.37|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.66||||41.66|12.35|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.66||||41.66|18.37|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.66||||41.66|12.35|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.66||||41.66|12.35|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.66||||41.66|28.75|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.66||||41.66|12.35|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|Self-pay|Self-pay|41.66||||41.66|14.58|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.66||||41.66|12.35|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.66||||41.66|12.35|28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.66||||41.66||28.75|12.35
10355|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM LARGE RIGHT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|AARP [1000]|AARP [100000]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|AETNA [1015]|AETNA [101529]|41.66||||41.66|18.37|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.66||||41.66|12.35|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|BCBS [1155]|BCBS UTHCT [115568]|41.66||||41.66|19.58|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.66||||41.66|20.83|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.66||||41.66|20.83|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.66||||41.66|26.25|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.66||||41.66|12.35|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|CIGNA [1260]|CIGNA GWH [126023]|41.66||||41.66|22.92|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.66||||41.66|28.75|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.66||||41.66|20.83|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.66||||41.66|18.37|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.66||||41.66|12.35|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.66||||41.66|18.37|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.66||||41.66|12.35|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.66||||41.66|12.35|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.66||||41.66|28.75|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.66||||41.66|12.35|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|Self-pay|Self-pay|41.66||||41.66|14.58|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.66||||41.66|12.35|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.66||||41.66|12.35|28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.66||||41.66||28.75|12.35
10356|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"WRIST SUPPORT LONG ELASTIC FREEDOM LARGE LEFT 7 1/4-8"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.66||||41.66||28.75|12.35
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.58||||1.58|0.7|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.58||||1.58|0.47|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.58||||1.58|0.74|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.58||||1.58|0.79|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.58||||1.58|0.79|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.58||||1.58|1|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.58||||1.58|0.47|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.58||||1.58|0.87|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.58||||1.58|1.09|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.58||||1.58|0.79|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.58||||1.58|0.7|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.58||||1.58|0.47|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.58||||1.58|0.7|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.58||||1.58|0.47|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.58||||1.58|0.47|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.58||||1.58|1.09|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.58||||1.58|0.47|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|Self-pay|Self-pay|1.58||||1.58|0.55|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.58||||1.58|0.47|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.58||||1.58|0.47|28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.58||||1.58||28.75|0.47
10357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.58||||1.58||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|AARP [1000]|AARP [100000]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|AETNA [1015]|AETNA [101529]|41.66||||41.66|18.37|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.66||||41.66|12.35|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|BCBS [1155]|BCBS UTHCT [115568]|41.66||||41.66|19.58|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.66||||41.66|20.83|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.66||||41.66|20.83|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.66||||41.66|26.25|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.66||||41.66|12.35|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|CIGNA [1260]|CIGNA GWH [126023]|41.66||||41.66|22.92|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.66||||41.66|28.75|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.66||||41.66|20.83|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.66||||41.66|18.37|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.66||||41.66|12.35|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.66||||41.66|18.37|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.66||||41.66|12.35|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.66||||41.66|12.35|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.66||||41.66|28.75|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.66||||41.66|12.35|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|Self-pay|Self-pay|41.66||||41.66|14.58|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.66||||41.66|12.35|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.66||||41.66|12.35|28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.66||||41.66||28.75|0.47
10357|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WRIST SUPPORT LONG ELASTIC FREEDOM X-LARGE RIGHT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.66||||41.66||28.75|0.47
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|AARP [1000]|AARP [100000]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|AETNA [1015]|AETNA [101529]|328.88||||328.88|145.04|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|328.88||||328.88|97.51|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|328.88||||328.88|154.57|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|328.88||||328.88|0|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|328.88||||328.88|164.44|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|328.88||||328.88|207.19|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|328.88||||328.88|97.51|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|328.88||||328.88|180.88|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|328.88||||328.88|226.93|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|328.88||||328.88|7.75|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|328.88||||328.88|145.04|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|328.88||||328.88|97.51|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|328.88||||328.88|145.04|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|328.88||||328.88|97.51|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|328.88||||328.88|97.51|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|328.88||||328.88|226.93|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|328.88||||328.88|97.51|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|Self-pay|Self-pay|328.88||||328.88|115.11|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|328.88||||328.88|97.51|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|328.88||||328.88|97.51|226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|328.88||||328.88||226.93|7.75
10358|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISOSULFAN BLUE 1 % SUBCUTANEOUS SOLUTION REPACK|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|328.88||||328.88||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AARP [1000]|AARP [100000]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AETNA [1015]|AETNA [101529]|41.14||||41.14|18.14|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.14||||41.14|12.2|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS [1155]|BCBS UTHCT [115568]|41.14||||41.14|19.33|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.14||||41.14|20.57|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.14||||41.14|20.57|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.14||||41.14|25.92|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.14||||41.14|12.2|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|CIGNA [1260]|CIGNA GWH [126023]|41.14||||41.14|22.63|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.14||||41.14|28.38|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.14||||41.14|20.57|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.14||||41.14|18.14|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.14||||41.14|12.2|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.14||||41.14|18.14|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.14||||41.14|12.2|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.14||||41.14|12.2|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.14||||41.14|28.38|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.14||||41.14|12.2|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|Self-pay|Self-pay|41.14||||41.14|14.4|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.14||||41.14|12.2|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.14||||41.14|12.2|226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.14||||41.14||226.93|7.75
10358|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.14||||41.14||226.93|7.75
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|AARP [1000]|AARP [100000]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|AETNA [1015]|AETNA [101529]|18.46||||18.46|8.14|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.46||||18.46|5.47|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|BCBS [1155]|BCBS UTHCT [115568]|18.46||||18.46|8.68|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.46||||18.46|9.23|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.46||||18.46|9.23|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.46||||18.46|11.63|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.46||||18.46|5.47|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|CIGNA [1260]|CIGNA GWH [126023]|18.46||||18.46|10.15|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|18.46||||18.46|12.74|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.46||||18.46|9.23|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.46||||18.46|8.14|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.46||||18.46|5.47|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.46||||18.46|8.14|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.46||||18.46|5.47|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.46||||18.46|5.47|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|18.46||||18.46|12.74|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.46||||18.46|5.47|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|Self-pay|Self-pay|18.46||||18.46|6.46|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.46||||18.46|5.47|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.46||||18.46|5.47|12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.46||||18.46||12.74|5.47
10360|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM FABRIC ENVELOPE STRAP W/SLIDING BUCKLESL DOUBL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|AARP [1000]|AARP [100000]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|AETNA [1015]|AETNA [101529]|18.46||||18.46|8.14|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.46||||18.46|5.47|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|BCBS [1155]|BCBS UTHCT [115568]|18.46||||18.46|8.68|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.46||||18.46|9.23|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.46||||18.46|9.23|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.46||||18.46|11.63|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.46||||18.46|5.47|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|CIGNA [1260]|CIGNA GWH [126023]|18.46||||18.46|10.15|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|18.46||||18.46|12.74|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.46||||18.46|9.23|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.46||||18.46|8.14|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.46||||18.46|5.47|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.46||||18.46|8.14|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.46||||18.46|5.47|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.46||||18.46|5.47|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|18.46||||18.46|12.74|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.46||||18.46|5.47|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|Self-pay|Self-pay|18.46||||18.46|6.46|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.46||||18.46|5.47|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.46||||18.46|5.47|12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.46||||18.46||12.74|5.47
10361|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SLING ARM SMALL FABRIC ENVELOPE STRAP W/SLDING BUCKLES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.46||||18.46||12.74|5.47
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|23.01||||23.01|10.15|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.01||||23.01|6.82|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|23.01||||23.01|10.81|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.01||||23.01|11.51|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.01||||23.01|11.51|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.01||||23.01|14.5|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.01||||23.01|6.82|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|23.01||||23.01|12.66|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|23.01||||23.01|15.88|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.01||||23.01|11.51|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.01||||23.01|10.15|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.01||||23.01|6.82|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.01||||23.01|10.15|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.01||||23.01|6.82|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.01||||23.01|6.82|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|23.01||||23.01|15.88|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.01||||23.01|6.82|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|23.01||||23.01|8.05|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.01||||23.01|6.82|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.01||||23.01|6.82|15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.01||||23.01||15.88|6.18
10364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ITRACONAZOLE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.01||||23.01||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|AARP [1000]|AARP [100000]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|AETNA [1015]|AETNA [101529]|20.83||||20.83|9.19|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.83||||20.83|6.18|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|BCBS [1155]|BCBS UTHCT [115568]|20.83||||20.83|9.79|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.83||||20.83|10.42|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.83||||20.83|10.42|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.83||||20.83|13.12|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.83||||20.83|6.18|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|CIGNA [1260]|CIGNA GWH [126023]|20.83||||20.83|11.46|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20.83||||20.83|14.37|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.83||||20.83|10.42|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.83||||20.83|9.19|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.83||||20.83|6.18|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.83||||20.83|9.19|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.83||||20.83|6.18|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.83||||20.83|6.18|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20.83||||20.83|14.37|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.83||||20.83|6.18|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|Self-pay|Self-pay|20.83||||20.83|7.29|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.83||||20.83|6.18|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.83||||20.83|6.18|15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.83||||20.83||15.88|6.18
10364|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM W/VELCRO CLOSURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.83||||20.83||15.88|6.18
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|AARP [1000]|AARP [100000]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|AETNA [1015]|AETNA [101529]|452.66||||452.66|199.62|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|452.66||||452.66|134.21|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|BCBS [1155]|BCBS UTHCT [115568]|452.66||||452.66|212.75|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|452.66||||452.66|226.33|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|452.66||||452.66|226.33|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|452.66||||452.66|285.18|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|452.66||||452.66|134.21|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|CIGNA [1260]|CIGNA GWH [126023]|452.66||||452.66|248.96|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|452.66||||452.66|312.34|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|452.66||||452.66|226.33|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|452.66||||452.66|199.62|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|452.66||||452.66|134.21|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|452.66||||452.66|199.62|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|452.66||||452.66|134.21|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|452.66||||452.66|134.21|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|452.66||||452.66|312.34|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|452.66||||452.66|134.21|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|Self-pay|Self-pay|452.66||||452.66|158.43|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|452.66||||452.66|134.21|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|452.66||||452.66|134.21|312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|452.66||||452.66||312.34|134.21
10365|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF SM/MED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|AARP [1000]|AARP [100000]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|AETNA [1015]|AETNA [101529]|452.66||||452.66|199.62|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|452.66||||452.66|134.21|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|BCBS [1155]|BCBS UTHCT [115568]|452.66||||452.66|212.75|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|452.66||||452.66|226.33|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|452.66||||452.66|226.33|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|452.66||||452.66|285.18|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|452.66||||452.66|134.21|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|CIGNA [1260]|CIGNA GWH [126023]|452.66||||452.66|248.96|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|452.66||||452.66|312.34|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|452.66||||452.66|226.33|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|452.66||||452.66|199.62|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|452.66||||452.66|134.21|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|452.66||||452.66|199.62|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|452.66||||452.66|134.21|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|452.66||||452.66|134.21|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|452.66||||452.66|312.34|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|452.66||||452.66|134.21|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|Self-pay|Self-pay|452.66||||452.66|158.43|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|452.66||||452.66|134.21|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|452.66||||452.66|134.21|312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|452.66||||452.66||312.34|134.21
10366|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF MED/LARGE. ROYCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|AARP [1000]|AARP [100000]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|AETNA [1015]|AETNA [101529]|452.66||||452.66|199.62|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|452.66||||452.66|134.21|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|BCBS [1155]|BCBS UTHCT [115568]|452.66||||452.66|212.75|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|452.66||||452.66|226.33|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|452.66||||452.66|226.33|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|452.66||||452.66|285.18|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|452.66||||452.66|134.21|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|CIGNA [1260]|CIGNA GWH [126023]|452.66||||452.66|248.96|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|452.66||||452.66|312.34|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|452.66||||452.66|226.33|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|452.66||||452.66|199.62|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|452.66||||452.66|134.21|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|452.66||||452.66|199.62|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|452.66||||452.66|134.21|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|452.66||||452.66|134.21|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|452.66||||452.66|312.34|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|452.66||||452.66|134.21|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|Self-pay|Self-pay|452.66||||452.66|158.43|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|452.66||||452.66|134.21|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|452.66||||452.66|134.21|312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|452.66||||452.66||312.34|134.21
10367|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF LARGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|452.66||||452.66||312.34|134.21
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.35||||3.35|1.48|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.35||||3.35|0.99|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.35||||3.35|1.57|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.35||||3.35|1.68|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.35||||3.35|1.68|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.35||||3.35|2.11|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.35||||3.35|0.99|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.35||||3.35|1.84|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.35||||3.35|2.31|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.35||||3.35|1.68|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.35||||3.35|1.48|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.35||||3.35|0.99|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.35||||3.35|1.48|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.35||||3.35|0.99|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.35||||3.35|0.99|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.35||||3.35|2.31|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.35||||3.35|0.99|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|Self-pay|Self-pay|3.35||||3.35|1.17|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.35||||3.35|0.99|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.35||||3.35|0.99|2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.35||||3.35||2.31|0.99
10371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.35||||3.35||2.31|0.99
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|34.1||||34.1|15.04|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.1||||34.1|10.11|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|34.1||||34.1|16.03|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.1||||34.1|17.05|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.1||||34.1|17.05|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.1||||34.1|21.48|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.1||||34.1|10.11|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|34.1||||34.1|18.76|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|34.1||||34.1|23.53|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34.1||||34.1|17.05|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.1||||34.1|15.04|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.1||||34.1|10.11|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.1||||34.1|15.04|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.1||||34.1|10.11|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|34.1||||34.1|10.11|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|34.1||||34.1|23.53|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.1||||34.1|10.11|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|34.1||||34.1|11.93|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34.1||||34.1|10.11|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.1||||34.1|10.11|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.1||||34.1||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|AARP [1000]|AARP [100000]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|AETNA [1015]|AETNA [101529]|155||||155|68.36|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|155||||155|45.96|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|BCBS [1155]|BCBS UTHCT [115568]|155||||155|72.85|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|155||||155|77.5|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|155||||155|77.5|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|155||||155|97.65|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|155||||155|45.96|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|CIGNA [1260]|CIGNA GWH [126023]|155||||155|85.25|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|155||||155|106.95|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|155||||155|77.5|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|155||||155|68.36|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|155||||155|45.96|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|155||||155|68.36|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|155||||155|45.96|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|155||||155|45.96|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|155||||155|106.95|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|155||||155|45.96|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|Self-pay|Self-pay|155||||155|54.25|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|155||||155|45.96|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|155||||155|45.96|106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|155||||155||106.95|10.11
10372|ERX|0250 - PHARMACY-GENERAL|LABETALOL 5 MG/ML INTRAVENOUS SOLUTION|40 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|155||||155||106.95|10.11
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.28||||1.28|0.56|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.28||||1.28|0.38|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.28||||1.28|0.6|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.28||||1.28|0.64|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.28||||1.28|0.64|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.28||||1.28|0.81|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.28||||1.28|0.38|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.28||||1.28|0.7|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.28||||1.28|0.88|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.28||||1.28|0.64|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.28||||1.28|0.56|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.28||||1.28|0.38|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.28||||1.28|0.56|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.28||||1.28|0.38|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.28||||1.28|0.38|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.28||||1.28|0.88|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.28||||1.28|0.38|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|1.28||||1.28|0.45|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.28||||1.28|0.38|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.28||||1.28|0.38|0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.28||||1.28||0.88|0.38
10373|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LABETALOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.28||||1.28||0.88|0.38
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|AARP [1000]|AARP [100000]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|AETNA [1015]|AETNA [101529]|2.29||||2.29|1.01|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.29||||2.29|0.68|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|BCBS [1155]|BCBS UTHCT [115568]|2.29||||2.29|1.07|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.29||||2.29|1.14|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.29||||2.29|1.14|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.29||||2.29|1.44|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.29||||2.29|0.68|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|CIGNA [1260]|CIGNA GWH [126023]|2.29||||2.29|1.26|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2.29||||2.29|1.58|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.29||||2.29|1.14|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.29||||2.29|1.01|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.29||||2.29|0.68|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.29||||2.29|1.01|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.29||||2.29|0.68|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.29||||2.29|0.68|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2.29||||2.29|1.58|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.29||||2.29|0.68|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|Self-pay|Self-pay|2.29||||2.29|0.8|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.29||||2.29|0.68|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.29||||2.29|0.68|1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.29||||2.29||1.58|0.68
10381|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPONGE DRAIN PRE-CUT 4 X 4 6-PLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.29||||2.29||1.58|0.68
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AARP [1000]|AARP [100000]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AETNA [1015]|AETNA [101529]|5.04||||5.04|2.22|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.04||||5.04|1.49|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BCBS UTHCT [115568]|5.04||||5.04|2.37|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.04||||5.04|2.52|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.04||||5.04|2.52|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.04||||5.04|3.18|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.04||||5.04|1.49|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|CIGNA [1260]|CIGNA GWH [126023]|5.04||||5.04|2.77|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.04||||5.04|3.48|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.04||||5.04|2.52|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.04||||5.04|2.22|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.04||||5.04|1.49|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.04||||5.04|2.22|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.04||||5.04|1.49|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.04||||5.04|1.49|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.04||||5.04|3.48|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.04||||5.04|1.49|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|Self-pay|Self-pay|5.04||||5.04|1.76|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.04||||5.04|1.49|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.04||||5.04|1.49|3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.04||||5.04||3.48|1.49
10384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPHILUS, BULGARICUS 100 MILLION CELL GRANULES PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.04||||5.04||3.48|1.49
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|AARP [1000]|AARP [100000]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|AETNA [1015]|AETNA [101529]|6.68||||6.68|2.95|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.68||||6.68|1.98|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|BCBS [1155]|BCBS UTHCT [115568]|6.68||||6.68|3.14|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.68||||6.68|3.34|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.68||||6.68|3.34|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.68||||6.68|4.21|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.68||||6.68|1.98|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|CIGNA [1260]|CIGNA GWH [126023]|6.68||||6.68|3.67|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6.68||||6.68|4.61|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.68||||6.68|3.34|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.68||||6.68|2.95|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.68||||6.68|1.98|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.68||||6.68|2.95|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.68||||6.68|1.98|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.68||||6.68|1.98|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6.68||||6.68|4.61|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.68||||6.68|1.98|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|Self-pay|Self-pay|6.68||||6.68|2.34|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.68||||6.68|1.98|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.68||||6.68|1.98|4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.68||||6.68||4.61|1.98
10388|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROGEL 4 X 4 WOUND DRESSING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.68||||6.68||4.61|1.98
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.84||||1.84|0.81|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.84||||1.84|0.55|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.84||||1.84|0.86|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.84||||1.84|0.92|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.84||||1.84|0.92|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.84||||1.84|1.16|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.84||||1.84|0.55|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.84||||1.84|1.01|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.84||||1.84|1.27|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.84||||1.84|0.92|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.84||||1.84|0.81|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.84||||1.84|0.55|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.84||||1.84|0.81|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.84||||1.84|0.55|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.84||||1.84|0.55|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.84||||1.84|1.27|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.84||||1.84|0.55|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.84||||1.84|0.64|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.84||||1.84|0.55|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.84||||1.84|0.55|1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.84||||1.84||1.27|0.55
103890|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMSULOSIN 0.4 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.84||||1.84||1.27|0.55
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|654.46||||654.46|288.62|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|654.46||||654.46|194.05|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|654.46||||654.46|307.6|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|654.46||||654.46|0|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|654.46||||654.46|327.23|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|654.46||||654.46|412.31|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|654.46||||654.46|194.05|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|654.46||||654.46|327.23|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|654.46||||654.46|451.58|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|654.46||||654.46|287.68|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|654.46||||654.46|288.62|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|654.46||||654.46|194.05|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|654.46||||654.46|288.62|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|654.46||||654.46|194.05|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|654.46||||654.46|194.05|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|654.46||||654.46|451.58|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|654.46||||654.46|194.05|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|654.46||||654.46|229.06|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|654.46||||654.46|194.05|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|654.46||||654.46|194.05|451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|654.46||||654.46||451.58|194.05
103895|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 13-VAL CONJ VACCINE-DIP CRM (PF) 0.5 ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|654.46||||654.46||451.58|194.05
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|AARP [1000]|AARP [100000]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|AETNA [1015]|AETNA [101529]|1.76||||1.76|0.78|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.76||||1.76|0.52|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|BCBS [1155]|BCBS UTHCT [115568]|1.76||||1.76|0.83|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.76||||1.76|0.88|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.76||||1.76|0.88|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.76||||1.76|1.11|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.76||||1.76|0.52|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|CIGNA [1260]|CIGNA GWH [126023]|1.76||||1.76|0.97|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1.76||||1.76|1.21|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.76||||1.76|0.88|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.76||||1.76|0.78|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.76||||1.76|0.52|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.76||||1.76|0.78|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.76||||1.76|0.52|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.76||||1.76|0.52|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1.76||||1.76|1.21|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.76||||1.76|0.52|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|Self-pay|Self-pay|1.76||||1.76|0.62|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.76||||1.76|0.52|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.76||||1.76|0.52|1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.76||||1.76||1.21|0.52
10391|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING TRANSPARENT 2"" X 3"" I.V. DRESSING"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.76||||1.76||1.21|0.52
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|2.17||||2.17|0.96|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.17||||2.17|0.64|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|2.17||||2.17|1.02|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.17||||2.17|1.09|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.17||||2.17|1.09|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.17||||2.17|1.37|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.17||||2.17|0.64|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|2.17||||2.17|1.19|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|2.17||||2.17|1.5|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.17||||2.17|1.09|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.17||||2.17|0.96|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.17||||2.17|0.64|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.17||||2.17|0.96|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.17||||2.17|0.64|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.17||||2.17|0.64|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|2.17||||2.17|1.5|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.17||||2.17|0.64|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|2.17||||2.17|0.76|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.17||||2.17|0.64|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.17||||2.17|0.64|1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.17||||2.17||1.5|0.64
104|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.17||||2.17||1.5|0.64
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.89||||0.89|0.39|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.89||||0.89|0.26|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.89||||0.89|0.42|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.89||||0.89|0.45|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.89||||0.89|0.45|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.89||||0.89|0.56|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.89||||0.89|0.26|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.89||||0.89|0.49|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.89||||0.89|0.61|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.89||||0.89|0.45|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.89||||0.89|0.39|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.89||||0.89|0.26|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.89||||0.89|0.39|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.89||||0.89|0.26|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.89||||0.89|0.26|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.89||||0.89|0.61|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.89||||0.89|0.26|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|Self-pay|Self-pay|0.89||||0.89|0.31|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.89||||0.89|0.26|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.89||||0.89|0.26|0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.89||||0.89||0.61|0.26
10403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 88 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.89||||0.89||0.61|0.26
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.68||||1.68|0.74|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.68||||1.68|0.5|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.68||||1.68|0.79|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.68||||1.68|0.84|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.68||||1.68|0.84|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.68||||1.68|1.06|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.68||||1.68|0.5|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.68||||1.68|0.92|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.68||||1.68|1.16|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.68||||1.68|0.84|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.68||||1.68|0.74|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.68||||1.68|0.5|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.68||||1.68|0.74|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.68||||1.68|0.5|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.68||||1.68|0.5|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.68||||1.68|1.16|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.68||||1.68|0.5|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|Self-pay|Self-pay|1.68||||1.68|0.59|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.68||||1.68|0.5|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.68||||1.68|0.5|1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.68||||1.68||1.16|0.5
10404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 112 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.68||||1.68||1.16|0.5
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.73||||1.73|0.76|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.73||||1.73|0.51|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.73||||1.73|0.81|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.73||||1.73|0.87|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.73||||1.73|0.87|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.73||||1.73|1.09|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.73||||1.73|0.51|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.73||||1.73|0.95|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.73||||1.73|1.19|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.73||||1.73|0.87|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.73||||1.73|0.76|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.73||||1.73|0.51|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.73||||1.73|0.76|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.73||||1.73|0.51|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.73||||1.73|0.51|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.73||||1.73|1.19|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.73||||1.73|0.51|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|Self-pay|Self-pay|1.73||||1.73|0.61|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.73||||1.73|0.51|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.73||||1.73|0.51|1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.73||||1.73||1.19|0.51
10405|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 137 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.73||||1.73||1.19|0.51
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|AARP [1000]|AARP [100000]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|AETNA [1015]|AETNA [101529]|24.08||||24.08|10.62|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.08||||24.08|7.14|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|BCBS [1155]|BCBS UTHCT [115568]|24.08||||24.08|11.32|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.08||||24.08|12.04|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.08||||24.08|12.04|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.08||||24.08|15.17|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.08||||24.08|7.14|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|CIGNA [1260]|CIGNA GWH [126023]|24.08||||24.08|13.25|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|24.08||||24.08|16.62|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.08||||24.08|12.04|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.08||||24.08|10.62|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.08||||24.08|7.14|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.08||||24.08|10.62|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.08||||24.08|7.14|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.08||||24.08|7.14|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|24.08||||24.08|16.62|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.08||||24.08|7.14|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|Self-pay|Self-pay|24.08||||24.08|8.43|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.08||||24.08|7.14|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.08||||24.08|7.14|16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.08||||24.08||16.62|7.14
10406|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE WITH IODOPHOR 1/2"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.08||||24.08||16.62|7.14
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|AARP [1000]|AARP [100000]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|AETNA [1015]|AETNA [101529]|10.02||||10.02|4.42|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.02||||10.02|2.97|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|BCBS [1155]|BCBS UTHCT [115568]|10.02||||10.02|4.71|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.02||||10.02|5.01|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.02||||10.02|5.01|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.02||||10.02|6.31|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.02||||10.02|2.97|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|CIGNA [1260]|CIGNA GWH [126023]|10.02||||10.02|5.51|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|10.02||||10.02|6.91|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.02||||10.02|5.01|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.02||||10.02|4.42|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.02||||10.02|2.97|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.02||||10.02|4.42|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.02||||10.02|2.97|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.02||||10.02|2.97|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|10.02||||10.02|6.91|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.02||||10.02|2.97|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|Self-pay|Self-pay|10.02||||10.02|3.51|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.02||||10.02|2.97|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.02||||10.02|2.97|6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.02||||10.02||6.91|2.97
10417|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 4 X 4 THIN LF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.02||||10.02||6.91|2.97
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|AARP [1000]|AARP [100000]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|AETNA [1015]|AETNA [101529]|31.38||||31.38|13.84|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.38||||31.38|9.3|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|BCBS [1155]|BCBS UTHCT [115568]|31.38||||31.38|14.75|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.38||||31.38|0|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.38||||31.38|15.69|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.38||||31.38|19.77|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.38||||31.38|9.3|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|CIGNA [1260]|CIGNA GWH [126023]|31.38||||31.38|17.26|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31.38||||31.38|21.65|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.38||||31.38|15.69|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.38||||31.38|13.84|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.38||||31.38|9.3|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.38||||31.38|13.84|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.38||||31.38|9.3|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.38||||31.38|9.3|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31.38||||31.38|21.65|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.38||||31.38|9.3|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|Self-pay|Self-pay|31.38||||31.38|10.98|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.38||||31.38|9.3|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.38||||31.38|9.3|21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.38||||31.38||21.65|9.3
10418|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING HYDROCOILLIOD DUODERM 6 X 6 TAPERED EDGE LF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.38||||31.38||21.65|9.3
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|AARP [1000]|AARP [100000]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|AETNA [1015]|AETNA [101529]|6.94||||6.94|3.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.94||||6.94|2.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|BCBS [1155]|BCBS UTHCT [115568]|6.94||||6.94|3.26|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.94||||6.94|3.47|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.94||||6.94|3.47|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.94||||6.94|4.37|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.94||||6.94|2.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|CIGNA [1260]|CIGNA GWH [126023]|6.94||||6.94|3.82|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6.94||||6.94|4.79|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.94||||6.94|3.47|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.94||||6.94|3.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.94||||6.94|2.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.94||||6.94|3.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.94||||6.94|2.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.94||||6.94|2.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6.94||||6.94|4.79|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.94||||6.94|2.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|Self-pay|Self-pay|6.94||||6.94|2.43|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.94||||6.94|2.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.94||||6.94|2.06|4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.94||||6.94||4.79|2.06
10419|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING XEROFORM 5X9|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.94||||6.94||4.79|2.06
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|AARP [1000]|AARP [100000]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|AETNA [1015]|AETNA [101529]|143.17||||143.17|63.14|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|143.17||||143.17|42.45|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|BCBS [1155]|BCBS UTHCT [115568]|143.17||||143.17|67.29|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|143.17||||143.17|71.58|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|143.17||||143.17|71.58|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|143.17||||143.17|90.2|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|143.17||||143.17|42.45|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|CIGNA [1260]|CIGNA GWH [126023]|143.17||||143.17|78.74|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|143.17||||143.17|98.79|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|143.17||||143.17|71.58|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|143.17||||143.17|63.14|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|143.17||||143.17|42.45|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|143.17||||143.17|63.14|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|143.17||||143.17|42.45|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|143.17||||143.17|42.45|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|143.17||||143.17|98.79|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|143.17||||143.17|42.45|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|Self-pay|Self-pay|143.17||||143.17|50.11|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|143.17||||143.17|42.45|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|143.17||||143.17|42.45|98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|143.17||||143.17||98.79|42.45
10422|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING MESALT RIBBON 3/4""X39"" 10/BOX. #MHC285299"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|143.17||||143.17||98.79|42.45
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|6.64||||6.64|2.93|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.64||||6.64|1.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|6.64||||6.64|3.12|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.64||||6.64|3.32|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.64||||6.64|3.32|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.64||||6.64|4.18|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.64||||6.64|1.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|6.64||||6.64|3.65|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.64||||6.64|4.58|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.64||||6.64|3.32|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.64||||6.64|2.93|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.64||||6.64|1.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.64||||6.64|2.93|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.64||||6.64|1.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.64||||6.64|1.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.64||||6.64|4.58|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.64||||6.64|1.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|Self-pay|Self-pay|6.64||||6.64|2.32|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.64||||6.64|1.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.64||||6.64|1.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.64||||6.64||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|15.81||||15.81|6.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.81||||15.81|4.69|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|15.81||||15.81|7.43|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.81||||15.81|7.91|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.81||||15.81|7.91|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.81||||15.81|9.96|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.81||||15.81|4.69|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|15.81||||15.81|8.7|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.81||||15.81|10.91|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.81||||15.81|7.91|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.81||||15.81|6.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.81||||15.81|4.69|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.81||||15.81|6.97|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.81||||15.81|4.69|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.81||||15.81|4.69|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.81||||15.81|10.91|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.81||||15.81|4.69|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|Self-pay|Self-pay|15.81||||15.81|5.53|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.81||||15.81|4.69|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.81||||15.81|4.69|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.81||||15.81||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|AARP [1000]|AARP [100000]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|11.16||||11.16|4.92|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.16||||11.16|3.31|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|11.16||||11.16|5.25|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.16||||11.16|5.58|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.16||||11.16|5.58|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.16||||11.16|7.03|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.16||||11.16|3.31|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|11.16||||11.16|6.14|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.16||||11.16|7.7|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.16||||11.16|5.58|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.16||||11.16|4.92|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.16||||11.16|3.31|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.16||||11.16|4.92|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.16||||11.16|3.31|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.16||||11.16|3.31|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.16||||11.16|7.7|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.16||||11.16|3.31|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|Self-pay|Self-pay|11.16||||11.16|3.91|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.16||||11.16|3.31|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.16||||11.16|3.31|10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.16||||11.16||10.91|1.97
10427|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.16||||11.16||10.91|1.97
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|22.88||||22.88|10.09|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.88||||22.88|6.78|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|22.88||||22.88|10.75|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.88||||22.88|11.44|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.88||||22.88|11.44|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.88||||22.88|14.41|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.88||||22.88|6.78|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|22.88||||22.88|12.58|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|22.88||||22.88|15.79|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22.88||||22.88|11.44|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.88||||22.88|10.09|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.88||||22.88|6.78|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.88||||22.88|10.09|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.88||||22.88|6.78|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|22.88||||22.88|6.78|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|22.88||||22.88|15.79|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.88||||22.88|6.78|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|Self-pay|Self-pay|22.88||||22.88|8.01|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22.88||||22.88|6.78|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.88||||22.88|6.78|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.88||||22.88||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|31.9||||31.9|14.07|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.9||||31.9|9.46|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|31.9||||31.9|14.99|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.9||||31.9|15.95|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.9||||31.9|15.95|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.9||||31.9|20.1|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.9||||31.9|9.46|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|31.9||||31.9|17.55|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|31.9||||31.9|22.01|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.9||||31.9|15.95|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.9||||31.9|14.07|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.9||||31.9|9.46|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.9||||31.9|14.07|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.9||||31.9|9.46|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.9||||31.9|9.46|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|31.9||||31.9|22.01|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.9||||31.9|9.46|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|Self-pay|Self-pay|31.9||||31.9|11.16|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.9||||31.9|9.46|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.9||||31.9|9.46|22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.9||||31.9||22.01|6.78
10428|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.9||||31.9||22.01|6.78
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|11.78||||11.78|5.19|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.78||||11.78|3.49|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|11.78||||11.78|5.54|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.78||||11.78|5.89|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.78||||11.78|5.89|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.78||||11.78|7.42|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.78||||11.78|3.49|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|11.78||||11.78|6.48|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.78||||11.78|8.13|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.78||||11.78|5.89|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.78||||11.78|5.19|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.78||||11.78|3.49|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.78||||11.78|5.19|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.78||||11.78|3.49|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.78||||11.78|3.49|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.78||||11.78|8.13|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.78||||11.78|3.49|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|Self-pay|Self-pay|11.78||||11.78|4.12|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.78||||11.78|3.49|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.78||||11.78|3.49|8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.78||||11.78||8.13|3.49
10430|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.78||||11.78||8.13|3.49
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|27.69||||27.69|12.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.69||||27.69|8.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|27.69||||27.69|13.01|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.69||||27.69|13.85|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.69||||27.69|13.85|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.69||||27.69|17.44|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.69||||27.69|8.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|27.69||||27.69|15.23|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.69||||27.69|19.11|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.69||||27.69|13.85|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.69||||27.69|12.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.69||||27.69|8.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.69||||27.69|12.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.69||||27.69|8.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.69||||27.69|8.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.69||||27.69|19.11|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.69||||27.69|8.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|Self-pay|Self-pay|27.69||||27.69|9.69|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.69||||27.69|8.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.69||||27.69|8.21|82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.69||||27.69||82.48|8.21
10431|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.69||||27.69||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|AARP [1000]|AARP [100000]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|AETNA [1015]|AETNA [101529]|119.53||||119.53|52.71|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|119.53||||119.53|35.44|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|BCBS [1155]|BCBS UTHCT [115568]|119.53||||119.53|56.18|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|119.53||||119.53|59.77|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|119.53||||119.53|59.77|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|119.53||||119.53|75.3|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|119.53||||119.53|35.44|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|CIGNA [1260]|CIGNA GWH [126023]|119.53||||119.53|65.74|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|119.53||||119.53|82.48|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|119.53||||119.53|59.77|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|119.53||||119.53|52.71|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|119.53||||119.53|35.44|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|119.53||||119.53|52.71|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|119.53||||119.53|35.44|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|119.53||||119.53|35.44|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|119.53||||119.53|82.48|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|119.53||||119.53|35.44|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|Self-pay|Self-pay|119.53||||119.53|41.84|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|119.53||||119.53|35.44|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|119.53||||119.53|35.44|82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|119.53||||119.53||82.48|8.21
10431|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DERMABOND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|119.53||||119.53||82.48|8.21
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|AARP [1000]|AARP [100000]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|AETNA [1015]|AETNA [101529]|70.14||||70.14|30.93|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70.14||||70.14|20.8|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|BCBS [1155]|BCBS UTHCT [115568]|70.14||||70.14|32.97|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70.14||||70.14|35.07|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70.14||||70.14|35.07|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70.14||||70.14|44.19|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70.14||||70.14|20.8|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|CIGNA [1260]|CIGNA GWH [126023]|70.14||||70.14|38.58|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70.14||||70.14|48.4|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70.14||||70.14|35.07|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70.14||||70.14|30.93|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70.14||||70.14|20.8|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70.14||||70.14|30.93|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70.14||||70.14|20.8|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70.14||||70.14|20.8|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70.14||||70.14|48.4|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70.14||||70.14|20.8|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|Self-pay|Self-pay|70.14||||70.14|24.55|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70.14||||70.14|20.8|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70.14||||70.14|20.8|48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70.14||||70.14||48.4|20.8
10432|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"COLLARCERVICAL RIGID CALIFORNIA SMALL 4.25"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|AARP [1000]|AARP [100000]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|AETNA [1015]|AETNA [101529]|70.14||||70.14|30.93|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70.14||||70.14|20.8|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|BCBS [1155]|BCBS UTHCT [115568]|70.14||||70.14|32.97|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70.14||||70.14|35.07|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70.14||||70.14|35.07|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70.14||||70.14|44.19|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70.14||||70.14|20.8|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|CIGNA [1260]|CIGNA GWH [126023]|70.14||||70.14|38.58|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70.14||||70.14|48.4|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70.14||||70.14|35.07|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70.14||||70.14|30.93|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70.14||||70.14|20.8|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70.14||||70.14|30.93|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70.14||||70.14|20.8|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70.14||||70.14|20.8|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70.14||||70.14|48.4|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70.14||||70.14|20.8|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|Self-pay|Self-pay|70.14||||70.14|24.55|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70.14||||70.14|20.8|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70.14||||70.14|20.8|48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70.14||||70.14||48.4|20.8
10433|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING MEDIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|AARP [1000]|AARP [100000]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|AETNA [1015]|AETNA [101529]|70.14||||70.14|30.93|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70.14||||70.14|20.8|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|BCBS [1155]|BCBS UTHCT [115568]|70.14||||70.14|32.97|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70.14||||70.14|35.07|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70.14||||70.14|35.07|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70.14||||70.14|44.19|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70.14||||70.14|20.8|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|CIGNA [1260]|CIGNA GWH [126023]|70.14||||70.14|38.58|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70.14||||70.14|48.4|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70.14||||70.14|35.07|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70.14||||70.14|30.93|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70.14||||70.14|20.8|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70.14||||70.14|30.93|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70.14||||70.14|20.8|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70.14||||70.14|20.8|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70.14||||70.14|48.4|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70.14||||70.14|20.8|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|Self-pay|Self-pay|70.14||||70.14|24.55|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70.14||||70.14|20.8|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70.14||||70.14|20.8|48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70.14||||70.14||48.4|20.8
10434|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|COLLAR PHILADELPHIA W. TRACH OPENING LARGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70.14||||70.14||48.4|20.8
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|AARP [1000]|AARP [100000]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|AETNA [1015]|AETNA [101529]|52.74||||52.74|23.26|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.74||||52.74|15.64|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|BCBS [1155]|BCBS UTHCT [115568]|52.74||||52.74|24.79|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.74||||52.74|26.37|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.74||||52.74|26.37|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.74||||52.74|33.23|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.74||||52.74|15.64|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|CIGNA [1260]|CIGNA GWH [126023]|52.74||||52.74|29.01|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|52.74||||52.74|36.39|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|52.74||||52.74|26.37|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.74||||52.74|23.26|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.74||||52.74|15.64|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.74||||52.74|23.26|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.74||||52.74|15.64|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|52.74||||52.74|15.64|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|52.74||||52.74|36.39|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.74||||52.74|15.64|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|Self-pay|Self-pay|52.74||||52.74|18.46|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|52.74||||52.74|15.64|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.74||||52.74|15.64|36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.74||||52.74||36.39|15.64
10440|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE POWERLOC 22 GA X .75"" 20/BOX. # B0652234"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.74||||52.74||36.39|15.64
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|1193.5||||1193.5|526.33|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1193.5||||1193.5|353.87|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|1193.5||||1193.5|560.95|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1193.5||||1193.5|596.75|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1193.5||||1193.5|596.75|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1193.5||||1193.5|751.91|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1193.5||||1193.5|353.87|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|1193.5||||1193.5|656.43|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1193.5||||1193.5|823.52|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1193.5||||1193.5|596.75|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1193.5||||1193.5|526.33|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1193.5||||1193.5|353.87|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1193.5||||1193.5|526.33|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1193.5||||1193.5|353.87|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1193.5||||1193.5|353.87|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1193.5||||1193.5|823.52|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1193.5||||1193.5|353.87|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|Self-pay|Self-pay|1193.5||||1193.5|417.72|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1193.5||||1193.5|353.87|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1193.5||||1193.5|353.87|823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1193.5||||1193.5||823.52|353.87
10442|ERX|0250 - PHARMACY-GENERAL|LIOTHYRONINE 10 MCG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1193.5||||1193.5||823.52|353.87
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.11||||2.11|0.93|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.11||||2.11|0.63|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.11||||2.11|0.99|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.11||||2.11|1.06|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.11||||2.11|1.06|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.11||||2.11|1.33|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.11||||2.11|0.63|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.11||||2.11|1.16|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.11||||2.11|1.46|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.11||||2.11|1.06|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.11||||2.11|0.93|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.11||||2.11|0.63|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.11||||2.11|0.93|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.11||||2.11|0.63|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.11||||2.11|0.63|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.11||||2.11|1.46|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.11||||2.11|0.63|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|Self-pay|Self-pay|2.11||||2.11|0.74|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.11||||2.11|0.63|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.11||||2.11|0.63|75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.11||||2.11||75.92|0.63
10443|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 5 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.11||||2.11||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|AARP [1000]|AARP [100000]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|AETNA [1015]|AETNA [101529]|110.03||||110.03|48.52|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|110.03||||110.03|32.62|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|BCBS [1155]|BCBS UTHCT [115568]|110.03||||110.03|51.71|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|110.03||||110.03|55.02|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|110.03||||110.03|55.02|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|110.03||||110.03|69.32|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|110.03||||110.03|32.62|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|CIGNA [1260]|CIGNA GWH [126023]|110.03||||110.03|60.52|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|110.03||||110.03|75.92|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|110.03||||110.03|55.02|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|110.03||||110.03|48.52|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|110.03||||110.03|32.62|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|110.03||||110.03|48.52|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|110.03||||110.03|32.62|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|110.03||||110.03|32.62|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|110.03||||110.03|75.92|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|110.03||||110.03|32.62|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|Self-pay|Self-pay|110.03||||110.03|38.51|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|110.03||||110.03|32.62|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|110.03||||110.03|32.62|75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|110.03||||110.03||75.92|0.63
10443|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ELECTRODE PADPRO PEDI QUICKCOMBO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|110.03||||110.03||75.92|0.63
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|AARP [1000]|AARP [100000]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|AETNA [1015]|AETNA [101529]|34.63||||34.63|15.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.63||||34.63|10.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|BCBS [1155]|BCBS UTHCT [115568]|34.63||||34.63|16.28|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.63||||34.63|17.32|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.63||||34.63|17.32|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.63||||34.63|21.82|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.63||||34.63|10.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|CIGNA [1260]|CIGNA GWH [126023]|34.63||||34.63|19.05|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34.63||||34.63|23.9|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34.63||||34.63|17.32|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.63||||34.63|15.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.63||||34.63|10.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.63||||34.63|15.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.63||||34.63|10.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34.63||||34.63|10.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34.63||||34.63|23.9|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.63||||34.63|10.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|Self-pay|Self-pay|34.63||||34.63|12.12|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34.63||||34.63|10.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.63||||34.63|10.27|23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.63||||34.63||23.9|10.27
10446|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 6"" X 4 YDS"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.63||||34.63||23.9|10.27
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|AARP [1000]|AARP [100000]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|AETNA [1015]|AETNA [101529]|14.15||||14.15|6.24|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.15||||14.15|4.2|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|BCBS [1155]|BCBS UTHCT [115568]|14.15||||14.15|6.65|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.15||||14.15|7.08|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.15||||14.15|7.08|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.15||||14.15|8.92|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.15||||14.15|4.2|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|CIGNA [1260]|CIGNA GWH [126023]|14.15||||14.15|7.78|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14.15||||14.15|9.76|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.15||||14.15|7.08|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.15||||14.15|6.24|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.15||||14.15|4.2|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.15||||14.15|6.24|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.15||||14.15|4.2|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.15||||14.15|4.2|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14.15||||14.15|9.76|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.15||||14.15|4.2|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|Self-pay|Self-pay|14.15||||14.15|4.95|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.15||||14.15|4.2|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.15||||14.15|4.2|9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.15||||14.15||9.76|4.2
10447|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 4"" X 4 YDS"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.15||||14.15||9.76|4.2
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|AARP [1000]|AARP [100000]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|AETNA [1015]|AETNA [101529]|11.25||||11.25|4.96|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.25||||11.25|3.34|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|BCBS [1155]|BCBS UTHCT [115568]|11.25||||11.25|5.29|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.25||||11.25|5.63|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.25||||11.25|5.63|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.25||||11.25|7.09|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.25||||11.25|3.34|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|CIGNA [1260]|CIGNA GWH [126023]|11.25||||11.25|6.19|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11.25||||11.25|7.76|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.25||||11.25|5.63|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.25||||11.25|4.96|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.25||||11.25|3.34|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.25||||11.25|4.96|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.25||||11.25|3.34|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.25||||11.25|3.34|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11.25||||11.25|7.76|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.25||||11.25|3.34|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|Self-pay|Self-pay|11.25||||11.25|3.94|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.25||||11.25|3.34|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.25||||11.25|3.34|7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.25||||11.25||7.76|3.34
10448|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 3"" X 4 YDS"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.25||||11.25||7.76|3.34
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.14||||0.14|0.06|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.14||||0.14|0.04|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.14||||0.14|0.07|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.14||||0.14|0.07|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.14||||0.14|0.07|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.14||||0.14|0.09|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.14||||0.14|0.04|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.14||||0.14|0.08|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.14||||0.14|0.1|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.14||||0.14|0.07|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.14||||0.14|0.06|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.14||||0.14|0.04|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.14||||0.14|0.06|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.14||||0.14|0.04|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.14||||0.14|0.04|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.14||||0.14|0.1|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.14||||0.14|0.04|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.14||||0.14|0.05|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.14||||0.14|0.04|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.14||||0.14|0.04|5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.14||||0.14||5.76|0.04
10449|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.14||||0.14||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|AARP [1000]|AARP [100000]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|AETNA [1015]|AETNA [101529]|8.35||||8.35|3.68|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.35||||8.35|2.48|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|BCBS [1155]|BCBS UTHCT [115568]|8.35||||8.35|3.92|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.35||||8.35|4.18|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.35||||8.35|4.18|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.35||||8.35|5.26|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.35||||8.35|2.48|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|CIGNA [1260]|CIGNA GWH [126023]|8.35||||8.35|4.59|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8.35||||8.35|5.76|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.35||||8.35|4.18|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.35||||8.35|3.68|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.35||||8.35|2.48|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.35||||8.35|3.68|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.35||||8.35|2.48|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.35||||8.35|2.48|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8.35||||8.35|5.76|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.35||||8.35|2.48|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|Self-pay|Self-pay|8.35||||8.35|2.92|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.35||||8.35|2.48|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.35||||8.35|2.48|5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.35||||8.35||5.76|0.04
10449|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"PADDING UNDERCAST WEBRIL 2"" X 4 YDS"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.35||||8.35||5.76|0.04
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.54||||0.54|0.24|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.54||||0.54|0.16|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.54||||0.54|0.25|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.54||||0.54|0.27|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.54||||0.54|0.27|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.54||||0.54|0.34|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.54||||0.54|0.16|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.54||||0.54|0.3|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.54||||0.54|0.37|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.54||||0.54|0.27|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.54||||0.54|0.24|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.54||||0.54|0.16|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.54||||0.54|0.24|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.54||||0.54|0.16|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.54||||0.54|0.16|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.54||||0.54|0.37|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.54||||0.54|0.16|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.54||||0.54|0.19|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.54||||0.54|0.16|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.54||||0.54|0.16|418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.54||||0.54||418.58|0.16
10451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.54||||0.54||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|AARP [1000]|AARP [100000]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|AETNA [1015]|AETNA [101529]|606.63||||606.63|267.53|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|606.63||||606.63|179.87|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|BCBS [1155]|BCBS UTHCT [115568]|606.63||||606.63|285.12|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|606.63||||606.63|303.32|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|606.63||||606.63|303.32|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|606.63||||606.63|382.18|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|606.63||||606.63|179.87|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|CIGNA [1260]|CIGNA GWH [126023]|606.63||||606.63|333.65|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|606.63||||606.63|418.58|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|606.63||||606.63|303.32|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|606.63||||606.63|267.53|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|606.63||||606.63|179.87|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|606.63||||606.63|267.53|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|606.63||||606.63|179.87|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|606.63||||606.63|179.87|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|606.63||||606.63|418.58|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|606.63||||606.63|179.87|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|Self-pay|Self-pay|606.63||||606.63|212.32|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|606.63||||606.63|179.87|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|606.63||||606.63|179.87|418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|606.63||||606.63||418.58|0.16
10451|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|WALKER DH PRESURE RELIEF XLARGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|606.63||||606.63||418.58|0.16
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|AARP [1000]|AARP [100000]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|AETNA [1015]|AETNA [101529]|609.72||||609.72|268.89|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|609.72||||609.72|180.78|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|BCBS [1155]|BCBS UTHCT [115568]|609.72||||609.72|286.57|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|609.72||||609.72|304.86|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|609.72||||609.72|304.86|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|609.72||||609.72|384.12|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|609.72||||609.72|180.78|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|CIGNA [1260]|CIGNA GWH [126023]|609.72||||609.72|335.35|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|609.72||||609.72|420.71|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|609.72||||609.72|286.57|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|609.72||||609.72|268.89|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|609.72||||609.72|180.78|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|609.72||||609.72|268.89|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|609.72||||609.72|180.78|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|609.72||||609.72|180.78|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|609.72||||609.72|420.71|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|609.72||||609.72|180.78|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|Self-pay|Self-pay|609.72||||609.72|213.4|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|609.72||||609.72|180.78|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|609.72||||609.72|180.78|420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|609.72||||609.72||420.71|180.78
10453|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|CENTRAL LINE KIT MULTI LUMEN PRESSURE INJECTABLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|609.72||||609.72||420.71|180.78
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.04||||1.04|0.46|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.04||||1.04|0.31|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.04||||1.04|0.49|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.04||||1.04|0.52|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.04||||1.04|0.52|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.04||||1.04|0.66|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.04||||1.04|0.31|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.04||||1.04|0.57|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.04||||1.04|0.72|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.04||||1.04|0.52|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.04||||1.04|0.46|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.04||||1.04|0.31|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.04||||1.04|0.46|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.04||||1.04|0.31|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.04||||1.04|0.31|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.04||||1.04|0.72|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.04||||1.04|0.31|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|1.04||||1.04|0.36|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.04||||1.04|0.31|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.04||||1.04|0.31|0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.04||||1.04||0.72|0.31
10454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.04||||1.04||0.72|0.31
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.34||||1.34|0.59|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.34||||1.34|0.4|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.34||||1.34|0.63|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.34||||1.34|0.67|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.34||||1.34|0.67|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.34||||1.34|0.84|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.34||||1.34|0.4|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.34||||1.34|0.74|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.34||||1.34|0.92|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.34||||1.34|0.67|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.34||||1.34|0.59|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.34||||1.34|0.4|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.34||||1.34|0.59|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.34||||1.34|0.4|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.34||||1.34|0.4|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.34||||1.34|0.92|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.34||||1.34|0.4|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|1.34||||1.34|0.47|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.34||||1.34|0.4|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.34||||1.34|0.4|0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.34||||1.34||0.92|0.4
10455|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.34||||1.34||0.92|0.4
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AARP [1000]|AARP [100000]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AETNA [1015]|AETNA [101529]|766.62||||766.62|338.08|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|766.62||||766.62|227.3|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS [1155]|BCBS UTHCT [115568]|766.62||||766.62|360.31|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|766.62||||766.62|383.31|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|766.62||||766.62|383.31|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|766.62||||766.62|482.97|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|766.62||||766.62|227.3|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|CIGNA [1260]|CIGNA GWH [126023]|766.62||||766.62|421.64|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|766.62||||766.62|528.97|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|766.62||||766.62|383.31|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|766.62||||766.62|338.08|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|766.62||||766.62|227.3|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|766.62||||766.62|338.08|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|766.62||||766.62|227.3|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|766.62||||766.62|227.3|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|766.62||||766.62|528.97|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|766.62||||766.62|227.3|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|Self-pay|Self-pay|766.62||||766.62|268.32|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|766.62||||766.62|227.3|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|766.62||||766.62|227.3|528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|766.62||||766.62||528.97|227.3
104566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE 500 MCG-SALMETEROL 50 MCG/DOSE BLISTR POWDR FOR INHALATION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|766.62||||766.62||528.97|227.3
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.15||||19.15|8.45|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.15||||19.15|5.68|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|19.15||||19.15|9|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.15||||19.15|9.58|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.15||||19.15|9.58|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.15||||19.15|12.06|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.15||||19.15|5.68|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|19.15||||19.15|10.53|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.15||||19.15|13.21|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.15||||19.15|9.58|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.15||||19.15|8.45|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.15||||19.15|5.68|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.15||||19.15|8.45|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.15||||19.15|5.68|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.15||||19.15|5.68|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.15||||19.15|13.21|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.15||||19.15|5.68|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|Self-pay|Self-pay|19.15||||19.15|6.7|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.15||||19.15|5.68|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.15||||19.15|5.68|13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.15||||19.15||13.21|5.68
104576|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRANEXAMIC ACID 650 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.15||||19.15||13.21|5.68
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|AARP [1000]|AARP [100000]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|AETNA [1015]|AETNA [101529]|13.45||||13.45|5.93|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.45||||13.45|3.99|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|BCBS [1155]|BCBS UTHCT [115568]|13.45||||13.45|6.32|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.45||||13.45|6.72|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.45||||13.45|6.72|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.45||||13.45|8.47|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.45||||13.45|3.99|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|CIGNA [1260]|CIGNA GWH [126023]|13.45||||13.45|7.4|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13.45||||13.45|9.28|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.45||||13.45|6.72|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.45||||13.45|5.93|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.45||||13.45|3.99|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.45||||13.45|5.93|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.45||||13.45|3.99|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.45||||13.45|3.99|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13.45||||13.45|9.28|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.45||||13.45|3.99|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|Self-pay|Self-pay|13.45||||13.45|4.71|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.45||||13.45|3.99|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.45||||13.45|3.99|9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.45||||13.45||9.28|3.99
10459|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PACKING GAUZE 1/4"" IODOPHORM"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.45||||13.45||9.28|3.99
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AARP [1000]|AARP [100000]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AETNA [1015]|AETNA [101529]|71.24||||71.24|31.42|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.24||||71.24|21.12|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BCBS UTHCT [115568]|71.24||||71.24|33.48|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.24||||71.24|35.62|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.24||||71.24|35.62|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.24||||71.24|44.88|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.24||||71.24|21.12|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|CIGNA [1260]|CIGNA GWH [126023]|71.24||||71.24|39.18|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|71.24||||71.24|49.16|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71.24||||71.24|35.62|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.24||||71.24|31.42|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.24||||71.24|21.12|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.24||||71.24|31.42|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.24||||71.24|21.12|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|71.24||||71.24|21.12|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|71.24||||71.24|49.16|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.24||||71.24|21.12|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|Self-pay|Self-pay|71.24||||71.24|24.93|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71.24||||71.24|21.12|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.24||||71.24|21.12|49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.24||||71.24||49.16|21.12
104604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAXIMIN 550 MG TABLET|0.5 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.24||||71.24||49.16|21.12
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|AARP [1000]|AARP [100000]|31.82||||31.82|14.32|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.82||||31.82||21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|AETNA [1015]|AETNA [101529]|31.82||||31.82|14.03|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.82||||31.82|9.43|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.82||||31.82||21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.82||||31.82||21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|BCBS [1155]|BCBS UTHCT [115568]|31.82||||31.82|14.96|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.82||||31.82|15.91|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.82||||31.82|15.91|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.82||||31.82|20.05|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.82||||31.82|9.43|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.82||||31.82||21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|CIGNA [1260]|CIGNA GWH [126023]|31.82||||31.82|17.5|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31.82||||31.82|21.96|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.82||||31.82|15.91|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.82||||31.82||21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.82||||31.82|14.03|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.82||||31.82|9.43|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.82||||31.82||21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.82||||31.82|14.03|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.82||||31.82|9.43|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.82||||31.82|9.43|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31.82||||31.82|21.96|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.82||||31.82|9.43|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|Self-pay|Self-pay|31.82||||31.82|11.14|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.82||||31.82|9.43|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.82||||31.82|9.43|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.82||||31.82|14.32|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.82||||31.82||21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.82||||31.82||21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.82||||31.82|14.32|21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.82||||31.82||21.96|9.43
10461|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STYLET INTUBATION 14FR SATIN SLIP FOR 5.0MM TO 10.0MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.82||||31.82||21.96|9.43
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|AARP [1000]|AARP [100000]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|AETNA [1015]|AETNA [101529]|94.4||||94.4|41.63|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94.4||||94.4|27.99|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|BCBS [1155]|BCBS UTHCT [115568]|94.4||||94.4|44.37|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|94.4||||94.4|47.2|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94.4||||94.4|47.2|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|94.4||||94.4|59.47|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|94.4||||94.4|27.99|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|CIGNA [1260]|CIGNA GWH [126023]|94.4||||94.4|51.92|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|GROUP PENSION ADMIN [1450]|GPA [145000]|94.4||||94.4|65.13|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|94.4||||94.4|47.2|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94.4||||94.4|41.63|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94.4||||94.4|27.99|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94.4||||94.4|41.63|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|94.4||||94.4|27.99|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|94.4||||94.4|27.99|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|PHCS [1780]|PHCS MULTIPLAN [178000]|94.4||||94.4|65.13|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94.4||||94.4|27.99|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|Self-pay|Self-pay|94.4||||94.4|33.04|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|94.4||||94.4|27.99|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|94.4||||94.4|27.99|65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94.4||||94.4||65.13|27.99
10462|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|INTRODUCER ET TUBE FLEX GUIDE 15FR 10/BOX. #GM85110|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|94.4||||94.4||65.13|27.99
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|AARP [1000]|AARP [100000]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|AETNA [1015]|AETNA [101529]|63.99||||63.99|28.22|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.99||||63.99|18.97|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|BCBS [1155]|BCBS UTHCT [115568]|63.99||||63.99|30.08|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63.99||||63.99|32|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63.99||||63.99|32|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63.99||||63.99|40.31|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63.99||||63.99|18.97|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|CIGNA [1260]|CIGNA GWH [126023]|63.99||||63.99|35.2|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63.99||||63.99|44.15|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63.99||||63.99|32|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.99||||63.99|28.22|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63.99||||63.99|18.97|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.99||||63.99|28.22|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63.99||||63.99|18.97|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63.99||||63.99|18.97|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63.99||||63.99|44.15|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63.99||||63.99|18.97|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|Self-pay|Self-pay|63.99||||63.99|22.4|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63.99||||63.99|18.97|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63.99||||63.99|18.97|44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63.99||||63.99||44.15|18.97
10463|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY TRAY ADD A FOLEY LATEX FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63.99||||63.99||44.15|18.97
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|3.66||||3.66|1.45|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.66||||3.66||2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|3.66||||3.66|1.66|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.66||||3.66|1.09|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.66||||3.66||2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.66||||3.66||2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|3.66||||3.66|1.72|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.66||||3.66|0|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.66||||3.66|1.83|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.66||||3.66|2.31|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.66||||3.66|1.09|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.66||||3.66||2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|3.66||||3.66|2.01|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.66||||3.66|2.53|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.66||||3.66|0.9|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.66||||3.66||2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.66||||3.66|1.66|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.66||||3.66|1.09|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.66||||3.66||2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.66||||3.66|1.66|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.66||||3.66|1.09|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.66||||3.66|1.09|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.66||||3.66|2.53|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.66||||3.66|1.09|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|3.66||||3.66|1.28|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.66||||3.66|1.09|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.66||||3.66|1.09|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.66||||3.66|1.45|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.66||||3.66||2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.66||||3.66||2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.66||||3.66|1.45|2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.66||||3.66||2.53|0.9
10467|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LORAZEPAM 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.66||||3.66||2.53|0.9
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|AARP [1000]|AARP [100000]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|AETNA [1015]|AETNA [101529]|88.11||||88.11|38.86|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|88.11||||88.11|26.13|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|BCBS [1155]|BCBS UTHCT [115568]|88.11||||88.11|41.41|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|88.11||||88.11|0|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|88.11||||88.11|44.06|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|88.11||||88.11|55.51|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|88.11||||88.11|26.13|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|CIGNA [1260]|CIGNA GWH [126023]|88.11||||88.11|48.46|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|88.11||||88.11|60.8|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|88.11||||88.11|44.06|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|88.11||||88.11|38.86|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|88.11||||88.11|26.13|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|88.11||||88.11|38.86|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|88.11||||88.11|26.13|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|88.11||||88.11|26.13|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|88.11||||88.11|60.8|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|88.11||||88.11|26.13|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|Self-pay|Self-pay|88.11||||88.11|30.84|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|88.11||||88.11|26.13|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|88.11||||88.11|26.13|60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|88.11||||88.11||60.8|26.13
10468|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 20 FR IC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|88.11||||88.11||60.8|26.13
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|AARP [1000]|AARP [100000]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|AETNA [1015]|AETNA [101529]|103||||103|45.42|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|103||||103|30.54|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|BCBS [1155]|BCBS UTHCT [115568]|103||||103|48.41|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|103||||103|0|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|103||||103|51.5|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|103||||103|64.89|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|103||||103|30.54|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|CIGNA [1260]|CIGNA GWH [126023]|103||||103|56.65|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|103||||103|71.07|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|103||||103|51.5|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|103||||103|45.42|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|103||||103|30.54|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|103||||103|45.42|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|103||||103|30.54|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|103||||103|30.54|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|103||||103|71.07|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|103||||103|30.54|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|Self-pay|Self-pay|103||||103|36.05|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|103||||103|30.54|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|103||||103|30.54|71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|103||||103||71.07|30.54
10469|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER COUDE 24 FR IC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|103||||103||71.07|30.54
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|AARP [1000]|AARP [100000]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|AETNA [1015]|AETNA [101529]|58.89||||58.89|25.97|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58.89||||58.89|17.46|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|BCBS [1155]|BCBS UTHCT [115568]|58.89||||58.89|27.68|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58.89||||58.89|29.45|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58.89||||58.89|29.45|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58.89||||58.89|37.1|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58.89||||58.89|17.46|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|CIGNA [1260]|CIGNA GWH [126023]|58.89||||58.89|32.39|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|58.89||||58.89|40.64|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58.89||||58.89|29.45|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58.89||||58.89|25.97|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58.89||||58.89|17.46|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58.89||||58.89|25.97|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.89||||58.89|17.46|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|58.89||||58.89|17.46|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|58.89||||58.89|40.64|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58.89||||58.89|17.46|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|Self-pay|Self-pay|58.89||||58.89|20.61|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58.89||||58.89|17.46|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58.89||||58.89|17.46|40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58.89||||58.89||40.64|17.46
10470|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY SILICON 14 FR LATEX FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58.89||||58.89||40.64|17.46
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|AARP [1000]|AARP [100000]|20.83||||20.83|9.37|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.83||||20.83||14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|AETNA [1015]|AETNA [101529]|20.83||||20.83|9.19|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.83||||20.83|6.18|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.83||||20.83||14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.83||||20.83||14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|BCBS [1155]|BCBS UTHCT [115568]|20.83||||20.83|9.79|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.83||||20.83|0|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.83||||20.83|10.42|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.83||||20.83|13.12|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.83||||20.83|6.18|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.83||||20.83||14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|CIGNA [1260]|CIGNA GWH [126023]|20.83||||20.83|11.46|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20.83||||20.83|14.37|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.83||||20.83|10.42|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.83||||20.83||14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.83||||20.83|9.19|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.83||||20.83|6.18|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.83||||20.83||14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.83||||20.83|9.19|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.83||||20.83|6.18|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.83||||20.83|6.18|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20.83||||20.83|14.37|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.83||||20.83|6.18|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|Self-pay|Self-pay|20.83||||20.83|7.29|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.83||||20.83|6.18|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.83||||20.83|6.18|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.83||||20.83|9.37|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.83||||20.83||14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.83||||20.83||14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.83||||20.83|9.37|14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.83||||20.83||14.37|6.18
10473|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CANNULA O2 ADULT DIVIDED 7' TUBING 25/CS. SALTER #|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.83||||20.83||14.37|6.18
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|AARP [1000]|AARP [100000]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|AETNA [1015]|AETNA [101529]|52.83||||52.83|23.3|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.83||||52.83|15.66|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|BCBS [1155]|BCBS UTHCT [115568]|52.83||||52.83|24.83|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.83||||52.83|26.41|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.83||||52.83|26.41|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.83||||52.83|33.28|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.83||||52.83|15.66|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|CIGNA [1260]|CIGNA GWH [126023]|52.83||||52.83|29.06|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|52.83||||52.83|36.45|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|52.83||||52.83|24.83|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.83||||52.83|23.3|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.83||||52.83|15.66|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.83||||52.83|23.3|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.83||||52.83|15.66|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|52.83||||52.83|15.66|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|52.83||||52.83|36.45|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.83||||52.83|15.66|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|Self-pay|Self-pay|52.83||||52.83|18.49|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|52.83||||52.83|15.66|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.83||||52.83|15.66|36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.83||||52.83||36.45|15.66
10475|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|"NEEDLE POWERLOC 20 GA X 1.5"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.83||||52.83||36.45|15.66
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|AARP [1000]|AARP [100000]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|AETNA [1015]|AETNA [101529]|88.11||||88.11|38.86|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|88.11||||88.11|26.13|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|BCBS [1155]|BCBS UTHCT [115568]|88.11||||88.11|41.41|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|88.11||||88.11|0|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|88.11||||88.11|44.06|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|88.11||||88.11|55.51|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|88.11||||88.11|26.13|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|CIGNA [1260]|CIGNA GWH [126023]|88.11||||88.11|48.46|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|88.11||||88.11|60.8|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|88.11||||88.11|44.06|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|88.11||||88.11|38.86|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|88.11||||88.11|26.13|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|88.11||||88.11|38.86|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|88.11||||88.11|26.13|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|88.11||||88.11|26.13|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|88.11||||88.11|60.8|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|88.11||||88.11|26.13|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|Self-pay|Self-pay|88.11||||88.11|30.84|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|88.11||||88.11|26.13|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|88.11||||88.11|26.13|60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|88.11||||88.11||60.8|26.13
10478|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 14 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|88.11||||88.11||60.8|26.13
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|AARP [1000]|AARP [100000]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|AETNA [1015]|AETNA [101529]|7.21||||7.21|3.18|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.21||||7.21|2.14|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|BCBS [1155]|BCBS UTHCT [115568]|7.21||||7.21|3.39|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.21||||7.21|3.6|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.21||||7.21|3.6|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.21||||7.21|4.54|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.21||||7.21|2.14|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|CIGNA [1260]|CIGNA GWH [126023]|7.21||||7.21|3.96|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7.21||||7.21|4.97|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.21||||7.21|3.6|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.21||||7.21|3.18|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.21||||7.21|2.14|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.21||||7.21|3.18|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.21||||7.21|2.14|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.21||||7.21|2.14|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7.21||||7.21|4.97|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.21||||7.21|2.14|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|Self-pay|Self-pay|7.21||||7.21|2.52|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.21||||7.21|2.14|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.21||||7.21|2.14|4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.21||||7.21||4.97|2.14
10479|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPLINT FINGER FROG STYLE PADDED MEDIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.21||||7.21||4.97|2.14
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AARP [1000]|AARP [100000]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AETNA [1015]|AETNA [101529]|41.14||||41.14|18.14|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.14||||41.14|12.2|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS [1155]|BCBS UTHCT [115568]|41.14||||41.14|19.33|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.14||||41.14|20.57|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.14||||41.14|20.57|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.14||||41.14|25.92|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.14||||41.14|12.2|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|CIGNA [1260]|CIGNA GWH [126023]|41.14||||41.14|22.63|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41.14||||41.14|28.38|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.14||||41.14|20.57|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.14||||41.14|18.14|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.14||||41.14|12.2|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.14||||41.14|18.14|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.14||||41.14|12.2|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.14||||41.14|12.2|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41.14||||41.14|28.38|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.14||||41.14|12.2|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|Self-pay|Self-pay|41.14||||41.14|14.4|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.14||||41.14|12.2|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.14||||41.14|12.2|28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.14||||41.14||28.38|12.2
10480|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.14||||41.14||28.38|12.2
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|AARP [1000]|AARP [100000]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|AETNA [1015]|AETNA [101529]|225.79||||225.79|99.57|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|225.79||||225.79|66.95|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|BCBS [1155]|BCBS UTHCT [115568]|225.79||||225.79|106.12|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|225.79||||225.79|112.89|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|225.79||||225.79|112.89|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|225.79||||225.79|142.25|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|225.79||||225.79|66.95|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|CIGNA [1260]|CIGNA GWH [126023]|225.79||||225.79|124.18|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|225.79||||225.79|155.79|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|225.79||||225.79|112.89|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|225.79||||225.79|99.57|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|225.79||||225.79|66.95|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|225.79||||225.79|99.57|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|225.79||||225.79|66.95|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|225.79||||225.79|66.95|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|225.79||||225.79|155.79|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|225.79||||225.79|66.95|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|Self-pay|Self-pay|225.79||||225.79|79.03|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|225.79||||225.79|66.95|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|225.79||||225.79|66.95|155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|225.79||||225.79||155.79|66.95
10481|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PICC LINE INSERTION KIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|225.79||||225.79||155.79|66.95
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|AARP [1000]|AARP [100000]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|AETNA [1015]|AETNA [101529]|132.77||||132.77|58.55|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132.77||||132.77|39.37|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|BCBS [1155]|BCBS UTHCT [115568]|132.77||||132.77|62.4|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132.77||||132.77|66.39|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132.77||||132.77|66.39|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132.77||||132.77|83.65|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132.77||||132.77|39.37|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|CIGNA [1260]|CIGNA GWH [126023]|132.77||||132.77|73.02|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|132.77||||132.77|91.61|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|132.77||||132.77|66.39|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132.77||||132.77|58.55|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132.77||||132.77|39.37|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132.77||||132.77|58.55|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132.77||||132.77|39.37|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|132.77||||132.77|39.37|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|132.77||||132.77|91.61|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132.77||||132.77|39.37|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|Self-pay|Self-pay|132.77||||132.77|46.47|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|132.77||||132.77|39.37|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132.77||||132.77|39.37|91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132.77||||132.77||91.61|39.37
10484|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL RIGHT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|AARP [1000]|AARP [100000]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|AETNA [1015]|AETNA [101529]|132.77||||132.77|58.55|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132.77||||132.77|39.37|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|BCBS [1155]|BCBS UTHCT [115568]|132.77||||132.77|62.4|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132.77||||132.77|66.39|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132.77||||132.77|66.39|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132.77||||132.77|83.65|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132.77||||132.77|39.37|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|CIGNA [1260]|CIGNA GWH [126023]|132.77||||132.77|73.02|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|132.77||||132.77|91.61|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|132.77||||132.77|66.39|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132.77||||132.77|58.55|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132.77||||132.77|39.37|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132.77||||132.77|58.55|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132.77||||132.77|39.37|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|132.77||||132.77|39.37|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|132.77||||132.77|91.61|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132.77||||132.77|39.37|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|Self-pay|Self-pay|132.77||||132.77|46.47|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|132.77||||132.77|39.37|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132.77||||132.77|39.37|91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132.77||||132.77||91.61|39.37
10485|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM RIGHT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132.77||||132.77||91.61|39.37
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|AARP [1000]|AARP [100000]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|AETNA [1015]|AETNA [101529]|126.26||||126.26|55.68|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126.26||||126.26|37.44|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|BCBS [1155]|BCBS UTHCT [115568]|126.26||||126.26|59.34|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126.26||||126.26|63.13|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126.26||||126.26|63.13|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126.26||||126.26|79.55|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126.26||||126.26|37.44|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|CIGNA [1260]|CIGNA GWH [126023]|126.26||||126.26|69.44|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126.26||||126.26|87.12|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|126.26||||126.26|63.13|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126.26||||126.26|55.68|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126.26||||126.26|37.44|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126.26||||126.26|55.68|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126.26||||126.26|37.44|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|126.26||||126.26|37.44|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126.26||||126.26|87.12|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126.26||||126.26|37.44|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|Self-pay|Self-pay|126.26||||126.26|44.19|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|126.26||||126.26|37.44|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126.26||||126.26|37.44|87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126.26||||126.26||87.12|37.44
10486|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE RIGHT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126.26||||126.26||87.12|37.44
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|AARP [1000]|AARP [100000]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|AETNA [1015]|AETNA [101529]|280.24||||280.24|123.59|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|280.24||||280.24|83.09|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|BCBS [1155]|BCBS UTHCT [115568]|280.24||||280.24|131.71|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|280.24||||280.24|140.12|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|280.24||||280.24|140.12|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|280.24||||280.24|176.55|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|280.24||||280.24|83.09|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|CIGNA [1260]|CIGNA GWH [126023]|280.24||||280.24|154.13|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|280.24||||280.24|193.37|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|280.24||||280.24|140.12|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|280.24||||280.24|123.59|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|280.24||||280.24|83.09|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|280.24||||280.24|123.59|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|280.24||||280.24|83.09|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|280.24||||280.24|83.09|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|280.24||||280.24|193.37|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|280.24||||280.24|83.09|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|Self-pay|Self-pay|280.24||||280.24|98.08|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|280.24||||280.24|83.09|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|280.24||||280.24|83.09|193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|280.24||||280.24||193.37|83.09
10487|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP SMALL LEFT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|280.24||||280.24||193.37|83.09
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|AARP [1000]|AARP [100000]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|AETNA [1015]|AETNA [101529]|132.77||||132.77|58.55|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132.77||||132.77|39.37|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|BCBS [1155]|BCBS UTHCT [115568]|132.77||||132.77|62.4|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132.77||||132.77|66.39|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132.77||||132.77|66.39|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132.77||||132.77|83.65|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132.77||||132.77|39.37|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|CIGNA [1260]|CIGNA GWH [126023]|132.77||||132.77|73.02|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|132.77||||132.77|91.61|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|132.77||||132.77|66.39|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132.77||||132.77|58.55|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132.77||||132.77|39.37|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132.77||||132.77|58.55|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132.77||||132.77|39.37|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|132.77||||132.77|39.37|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|132.77||||132.77|91.61|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132.77||||132.77|39.37|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|Self-pay|Self-pay|132.77||||132.77|46.47|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|132.77||||132.77|39.37|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132.77||||132.77|39.37|91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132.77||||132.77||91.61|39.37
10488|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP MEDIUM LEFT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132.77||||132.77||91.61|39.37
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.72||||6.72|2.96|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.72||||6.72|1.99|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|6.72||||6.72|3.16|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.72||||6.72|3.36|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.72||||6.72|3.36|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.72||||6.72|4.23|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.72||||6.72|1.99|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|6.72||||6.72|3.7|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.72||||6.72|4.64|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.72||||6.72|3.36|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.72||||6.72|2.96|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.72||||6.72|1.99|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.72||||6.72|2.96|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.72||||6.72|1.99|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.72||||6.72|1.99|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.72||||6.72|4.64|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.72||||6.72|1.99|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|Self-pay|Self-pay|6.72||||6.72|2.35|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.72||||6.72|1.99|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.72||||6.72|1.99|4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.72||||6.72||4.64|1.99
104886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOMEFOLATE CALCIUM 7.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.72||||6.72||4.64|1.99
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|AARP [1000]|AARP [100000]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|AETNA [1015]|AETNA [101529]|126.26||||126.26|55.68|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126.26||||126.26|37.44|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|BCBS [1155]|BCBS UTHCT [115568]|126.26||||126.26|59.34|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126.26||||126.26|63.13|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126.26||||126.26|63.13|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126.26||||126.26|79.55|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126.26||||126.26|37.44|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|CIGNA [1260]|CIGNA GWH [126023]|126.26||||126.26|69.44|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126.26||||126.26|87.12|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|126.26||||126.26|63.13|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126.26||||126.26|55.68|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126.26||||126.26|37.44|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126.26||||126.26|55.68|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126.26||||126.26|37.44|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|126.26||||126.26|37.44|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126.26||||126.26|87.12|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126.26||||126.26|37.44|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|Self-pay|Self-pay|126.26||||126.26|44.19|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|126.26||||126.26|37.44|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126.26||||126.26|37.44|87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126.26||||126.26||87.12|37.44
10489|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|ANKLE BRACE STIRRUP LARGE LEFT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126.26||||126.26||87.12|37.44
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|AARP [1000]|AARP [100000]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|AETNA [1015]|AETNA [101529]|170.39||||170.39|75.14|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170.39||||170.39|50.52|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|BCBS [1155]|BCBS UTHCT [115568]|170.39||||170.39|80.09|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170.39||||170.39|85.2|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170.39||||170.39|85.2|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170.39||||170.39|107.35|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170.39||||170.39|50.52|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|CIGNA [1260]|CIGNA GWH [126023]|170.39||||170.39|93.72|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|GROUP PENSION ADMIN [1450]|GPA [145000]|170.39||||170.39|117.57|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|170.39||||170.39|85.2|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170.39||||170.39|75.14|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170.39||||170.39|50.52|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170.39||||170.39|75.14|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|170.39||||170.39|50.52|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|170.39||||170.39|50.52|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|PHCS [1780]|PHCS MULTIPLAN [178000]|170.39||||170.39|117.57|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170.39||||170.39|50.52|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|Self-pay|Self-pay|170.39||||170.39|59.63|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|170.39||||170.39|50.52|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170.39||||170.39|50.52|117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170.39||||170.39||117.57|50.52
10490|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|STAPLER SKIN PROXIMATE 35 CT 6/BOX. #PMW35|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|170.39||||170.39||117.57|50.52
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|AARP [1000]|AARP [100000]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|AETNA [1015]|AETNA [101529]|88.11||||88.11|38.86|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|88.11||||88.11|26.13|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|BCBS [1155]|BCBS UTHCT [115568]|88.11||||88.11|41.41|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|88.11||||88.11|0|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|88.11||||88.11|44.06|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|88.11||||88.11|55.51|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|88.11||||88.11|26.13|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|CIGNA [1260]|CIGNA GWH [126023]|88.11||||88.11|48.46|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|88.11||||88.11|60.8|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|88.11||||88.11|44.06|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|88.11||||88.11|38.86|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|88.11||||88.11|26.13|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|88.11||||88.11|38.86|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|88.11||||88.11|26.13|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|88.11||||88.11|26.13|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|88.11||||88.11|60.8|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|88.11||||88.11|26.13|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|Self-pay|Self-pay|88.11||||88.11|30.84|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|88.11||||88.11|26.13|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|88.11||||88.11|26.13|60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|88.11||||88.11||60.8|26.13
10496|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 18 FR 5CC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|88.11||||88.11||60.8|26.13
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|AARP [1000]|AARP [100000]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|AETNA [1015]|AETNA [101529]|74.89||||74.89|33.03|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.89||||74.89|22.21|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|BCBS [1155]|BCBS UTHCT [115568]|74.89||||74.89|35.2|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.89||||74.89|0|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.89||||74.89|37.45|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.89||||74.89|47.18|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.89||||74.89|22.21|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|CIGNA [1260]|CIGNA GWH [126023]|74.89||||74.89|41.19|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74.89||||74.89|51.67|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.89||||74.89|37.45|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.89||||74.89|33.03|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.89||||74.89|22.21|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.89||||74.89|33.03|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.89||||74.89|22.21|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.89||||74.89|22.21|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74.89||||74.89|51.67|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.89||||74.89|22.21|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|Self-pay|Self-pay|74.89||||74.89|26.21|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.89||||74.89|22.21|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.89||||74.89|22.21|51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.89||||74.89||51.67|22.21
10497|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY COUDE 22 FR 5CC 12/CASE. # 0168SI22|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.89||||74.89||51.67|22.21
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|AARP [1000]|AARP [100000]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|AETNA [1015]|AETNA [101529]|91.93||||91.93|40.54|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|91.93||||91.93|27.26|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|BCBS [1155]|BCBS UTHCT [115568]|91.93||||91.93|43.21|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|91.93||||91.93|45.96|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|91.93||||91.93|45.96|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|91.93||||91.93|57.92|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|91.93||||91.93|27.26|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|CIGNA [1260]|CIGNA GWH [126023]|91.93||||91.93|50.56|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|91.93||||91.93|63.43|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|91.93||||91.93|45.96|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|91.93||||91.93|40.54|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|91.93||||91.93|27.26|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|91.93||||91.93|40.54|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|91.93||||91.93|27.26|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|91.93||||91.93|27.26|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|91.93||||91.93|63.43|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|91.93||||91.93|27.26|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|Self-pay|Self-pay|91.93||||91.93|32.18|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|91.93||||91.93|27.26|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|91.93||||91.93|27.26|63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|91.93||||91.93||63.43|27.26
10498|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 16FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|91.93||||91.93||63.43|27.26
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|AARP [1000]|AARP [100000]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|AETNA [1015]|AETNA [101529]|95.22||||95.22|41.99|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95.22||||95.22|28.23|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|BCBS [1155]|BCBS UTHCT [115568]|95.22||||95.22|44.75|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|95.22||||95.22|47.61|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|95.22||||95.22|47.61|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|95.22||||95.22|59.99|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|95.22||||95.22|28.23|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|CIGNA [1260]|CIGNA GWH [126023]|95.22||||95.22|52.37|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|95.22||||95.22|65.7|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|95.22||||95.22|47.61|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95.22||||95.22|41.99|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95.22||||95.22|28.23|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95.22||||95.22|41.99|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|95.22||||95.22|28.23|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|95.22||||95.22|28.23|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|95.22||||95.22|65.7|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95.22||||95.22|28.23|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|Self-pay|Self-pay|95.22||||95.22|33.33|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|95.22||||95.22|28.23|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|95.22||||95.22|28.23|65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95.22||||95.22||65.7|28.23
10499|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH FOLEY COUNCIL 5CC RED LATEX 18FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|95.22||||95.22||65.7|28.23
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|0.87||||0.87|0.38|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.87||||0.87|0.26|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|0.87||||0.87|0.41|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.87||||0.87|0.44|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.87||||0.87|0.44|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.87||||0.87|0.55|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.87||||0.87|0.26|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|0.87||||0.87|0.48|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|0.87||||0.87|0.6|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.87||||0.87|0.44|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.87||||0.87|0.38|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.87||||0.87|0.26|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.87||||0.87|0.38|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.87||||0.87|0.26|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.87||||0.87|0.26|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|0.87||||0.87|0.6|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.87||||0.87|0.26|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|0.87||||0.87|0.3|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.87||||0.87|0.26|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.87||||0.87|0.26|0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.87||||0.87||0.6|0.26
105|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.87||||0.87||0.6|0.26
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|AARP [1000]|AARP [100000]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|AETNA [1015]|AETNA [101529]|71.73||||71.73|31.63|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.73||||71.73|21.27|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|BCBS [1155]|BCBS UTHCT [115568]|71.73||||71.73|33.71|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.73||||71.73|35.86|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.73||||71.73|35.86|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.73||||71.73|45.19|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.73||||71.73|21.27|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|CIGNA [1260]|CIGNA GWH [126023]|71.73||||71.73|39.45|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71.73||||71.73|49.49|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71.73||||71.73|35.86|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.73||||71.73|31.63|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.73||||71.73|21.27|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.73||||71.73|31.63|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.73||||71.73|21.27|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|71.73||||71.73|21.27|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71.73||||71.73|49.49|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.73||||71.73|21.27|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|Self-pay|Self-pay|71.73||||71.73|25.11|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71.73||||71.73|21.27|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.73||||71.73|21.27|49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.73||||71.73||49.49|21.27
10500|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY ALCOCK 22FR 3 WAY 30CC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.73||||71.73||49.49|21.27
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|AARP [1000]|AARP [100000]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|AETNA [1015]|AETNA [101529]|68.3||||68.3|30.12|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|68.3||||68.3|20.25|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|BCBS [1155]|BCBS UTHCT [115568]|68.3||||68.3|32.1|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|68.3||||68.3|34.15|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|68.3||||68.3|34.15|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|68.3||||68.3|43.03|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|68.3||||68.3|20.25|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|CIGNA [1260]|CIGNA GWH [126023]|68.3||||68.3|37.56|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|68.3||||68.3|47.13|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|68.3||||68.3|34.15|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|68.3||||68.3|30.12|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|68.3||||68.3|20.25|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|68.3||||68.3|30.12|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|68.3||||68.3|20.25|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|68.3||||68.3|20.25|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|68.3||||68.3|47.13|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|68.3||||68.3|20.25|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|Self-pay|Self-pay|68.3||||68.3|23.91|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|68.3||||68.3|20.25|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|68.3||||68.3|20.25|47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|68.3||||68.3||47.13|20.25
10501|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 8FR 2 WAY 3CC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|68.3||||68.3||47.13|20.25
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|AARP [1000]|AARP [100000]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|AETNA [1015]|AETNA [101529]|54.06||||54.06|23.84|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54.06||||54.06|16.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|BCBS [1155]|BCBS UTHCT [115568]|54.06||||54.06|25.41|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54.06||||54.06|27.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54.06||||54.06|27.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54.06||||54.06|34.06|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54.06||||54.06|16.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|CIGNA [1260]|CIGNA GWH [126023]|54.06||||54.06|29.73|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54.06||||54.06|37.3|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54.06||||54.06|27.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54.06||||54.06|23.84|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54.06||||54.06|16.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54.06||||54.06|23.84|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54.06||||54.06|16.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54.06||||54.06|16.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54.06||||54.06|37.3|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54.06||||54.06|16.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|Self-pay|Self-pay|54.06||||54.06|18.92|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54.06||||54.06|16.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54.06||||54.06|16.03|37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54.06||||54.06||37.3|16.03
10502|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY 18FR 2 WAY 3CC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54.06||||54.06||37.3|16.03
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|AARP [1000]|AARP [100000]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|425.43||||425.43|336.38|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|425.43||||425.43|126.14|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|425.43||||425.43|199.95|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|425.43||||425.43|0|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|425.43||||425.43|212.72|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|425.43||||425.43|268.02|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|425.43||||425.43|126.14|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|425.43||||425.43|233.99|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|425.43||||425.43|293.55|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|425.43||||425.43|15.01|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|425.43||||425.43|336.38|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|425.43||||425.43|126.14|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|425.43||||425.43|336.38|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|425.43||||425.43|126.14|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|425.43||||425.43|126.14|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|425.43||||425.43|293.55|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|425.43||||425.43|126.14|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|Self-pay|Self-pay|425.43||||425.43|148.9|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|425.43||||425.43|126.14|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|425.43||||425.43|126.14|336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|425.43||||425.43||336.38|15.01
105029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE,PROCAIN 900,000 UNIT-300K UNIT/2 ML IM SYRINGE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|425.43||||425.43||336.38|15.01
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|AARP [1000]|AARP [100000]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|AETNA [1015]|AETNA [101529]|35.78||||35.78|15.78|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.78||||35.78|10.61|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|BCBS [1155]|BCBS UTHCT [115568]|35.78||||35.78|16.81|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.78||||35.78|17.89|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.78||||35.78|17.89|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.78||||35.78|22.54|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.78||||35.78|10.61|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|CIGNA [1260]|CIGNA GWH [126023]|35.78||||35.78|19.68|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|35.78||||35.78|24.68|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35.78||||35.78|17.89|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.78||||35.78|15.78|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.78||||35.78|10.61|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.78||||35.78|15.78|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.78||||35.78|10.61|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|35.78||||35.78|10.61|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|35.78||||35.78|24.68|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.78||||35.78|10.61|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|Self-pay|Self-pay|35.78||||35.78|12.53|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35.78||||35.78|10.61|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.78||||35.78|10.61|24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.78||||35.78||24.68|10.61
10503|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|CERVICAL COLLAR CONTOURED FOAM WITH VELCRO CLOSURE XLARGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.78||||35.78||24.68|10.61
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|AARP [1000]|AARP [100000]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|AETNA [1015]|AETNA [101529]|304.86||||304.86|134.44|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|304.86||||304.86|90.39|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|BCBS [1155]|BCBS UTHCT [115568]|304.86||||304.86|143.29|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|304.86||||304.86|152.43|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|304.86||||304.86|152.43|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|304.86||||304.86|192.06|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|304.86||||304.86|90.39|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|CIGNA [1260]|CIGNA GWH [126023]|304.86||||304.86|167.67|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|304.86||||304.86|210.36|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|304.86||||304.86|152.43|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|304.86||||304.86|134.44|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|304.86||||304.86|90.39|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|304.86||||304.86|134.44|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|304.86||||304.86|90.39|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|304.86||||304.86|90.39|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|304.86||||304.86|210.36|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|304.86||||304.86|90.39|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|Self-pay|Self-pay|304.86||||304.86|106.7|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|304.86||||304.86|90.39|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|304.86||||304.86|90.39|210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|304.86||||304.86||210.36|90.39
10507|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|OPEP AEROBIKA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|304.86||||304.86||210.36|90.39
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|AARP [1000]|AARP [100000]|3076.79||||3076.79|1384.55|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3076.79||||3076.79||2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|AETNA [1015]|AETNA [101529]|3076.79||||3076.79|1356.86|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3076.79||||3076.79|912.27|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3076.79||||3076.79||2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3076.79||||3076.79||2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|BCBS [1155]|BCBS UTHCT [115568]|3076.79||||3076.79|1446.09|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3076.79||||3076.79|1538.39|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3076.79||||3076.79|1538.39|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3076.79||||3076.79|1938.37|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3076.79||||3076.79|912.27|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3076.79||||3076.79||2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|CIGNA [1260]|CIGNA GWH [126023]|3076.79||||3076.79|1692.23|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3076.79||||3076.79|2122.98|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3076.79||||3076.79|1538.39|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3076.79||||3076.79||2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3076.79||||3076.79|1356.86|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3076.79||||3076.79|912.27|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3076.79||||3076.79||2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3076.79||||3076.79|1356.86|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3076.79||||3076.79|912.27|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3076.79||||3076.79|912.27|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3076.79||||3076.79|2122.98|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3076.79||||3076.79|912.27|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|Self-pay|Self-pay|3076.79||||3076.79|1076.88|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3076.79||||3076.79|912.27|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3076.79||||3076.79|912.27|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3076.79||||3076.79|1384.55|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3076.79||||3076.79||2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3076.79||||3076.79||2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3076.79||||3076.79|1384.55|2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3076.79||||3076.79||2122.98|912.27
10510|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX CATHETER KIT CAREFUSION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3076.79||||3076.79||2122.98|912.27
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|AARP [1000]|AARP [100000]|356.95||||356.95|160.63|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|356.95||||356.95||246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|AETNA [1015]|AETNA [101529]|356.95||||356.95|157.41|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|356.95||||356.95|105.84|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|356.95||||356.95||246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|356.95||||356.95||246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|BCBS [1155]|BCBS UTHCT [115568]|356.95||||356.95|167.77|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|356.95||||356.95|178.48|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|356.95||||356.95|178.48|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|356.95||||356.95|224.88|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|356.95||||356.95|105.84|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|356.95||||356.95||246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|CIGNA [1260]|CIGNA GWH [126023]|356.95||||356.95|196.32|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|GROUP PENSION ADMIN [1450]|GPA [145000]|356.95||||356.95|246.3|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|356.95||||356.95|178.48|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|356.95||||356.95||246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|356.95||||356.95|157.41|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|356.95||||356.95|105.84|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|356.95||||356.95||246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|356.95||||356.95|157.41|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|356.95||||356.95|105.84|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|356.95||||356.95|105.84|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|PHCS [1780]|PHCS MULTIPLAN [178000]|356.95||||356.95|246.3|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|356.95||||356.95|105.84|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|Self-pay|Self-pay|356.95||||356.95|124.93|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|356.95||||356.95|105.84|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|356.95||||356.95|105.84|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|356.95||||356.95|160.63|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|356.95||||356.95||246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|356.95||||356.95||246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|356.95||||356.95|160.63|246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|356.95||||356.95||246.3|105.84
10511|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PLEURX DRAINAGE KIT 500ML|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|356.95||||356.95||246.3|105.84
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|AARP [1000]|AARP [100000]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|AETNA [1015]|AETNA [101529]|263.7||||263.7|116.29|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|263.7||||263.7|78.19|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|263.7||||263.7|123.94|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|263.7||||263.7|0|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|263.7||||263.7|131.85|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|263.7||||263.7|166.13|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|263.7||||263.7|78.19|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|263.7||||263.7|145.04|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|263.7||||263.7|181.95|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|263.7||||263.7|131.85|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|263.7||||263.7|116.29|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|263.7||||263.7|78.19|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|263.7||||263.7|116.29|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|263.7||||263.7|78.19|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|263.7||||263.7|78.19|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|263.7||||263.7|181.95|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|263.7||||263.7|78.19|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|Self-pay|Self-pay|263.7||||263.7|92.29|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|263.7||||263.7|78.19|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|263.7||||263.7|78.19|181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|263.7||||263.7||181.95|78.19
10512|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBELLA VACCINE LIVE(PF)1,000-12,500TCID50/0.5 ML SUBCUT|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|263.7||||263.7||181.95|78.19
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|AARP [1000]|AARP [100000]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|AETNA [1015]|AETNA [101529]|63.29||||63.29|27.91|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.29||||63.29|18.76|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|BCBS [1155]|BCBS UTHCT [115568]|63.29||||63.29|29.75|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63.29||||63.29|31.64|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63.29||||63.29|31.64|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63.29||||63.29|39.87|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63.29||||63.29|18.76|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|CIGNA [1260]|CIGNA GWH [126023]|63.29||||63.29|34.81|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63.29||||63.29|43.67|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63.29||||63.29|31.64|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.29||||63.29|27.91|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63.29||||63.29|18.76|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.29||||63.29|27.91|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63.29||||63.29|18.76|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63.29||||63.29|18.76|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63.29||||63.29|43.67|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63.29||||63.29|18.76|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|Self-pay|Self-pay|63.29||||63.29|22.15|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63.29||||63.29|18.76|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63.29||||63.29|18.76|43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63.29||||63.29||43.67|18.76
10513|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"DRESSING PURACOL COLLAGEN PLUS AG 2 X 2"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63.29||||63.29||43.67|18.76
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|AARP [1000]|AARP [100000]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|AETNA [1015]|AETNA [101529]|217.83||||217.83|96.06|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217.83||||217.83|64.59|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|BCBS [1155]|BCBS UTHCT [115568]|217.83||||217.83|102.38|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217.83||||217.83|108.91|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217.83||||217.83|108.91|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217.83||||217.83|137.23|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217.83||||217.83|64.59|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|CIGNA [1260]|CIGNA GWH [126023]|217.83||||217.83|119.8|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|217.83||||217.83|150.3|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|217.83||||217.83|108.91|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217.83||||217.83|96.06|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217.83||||217.83|64.59|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217.83||||217.83|96.06|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217.83||||217.83|64.59|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|217.83||||217.83|64.59|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|217.83||||217.83|150.3|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217.83||||217.83|64.59|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|Self-pay|Self-pay|217.83||||217.83|76.24|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|217.83||||217.83|64.59|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217.83||||217.83|64.59|150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217.83||||217.83||150.3|64.59
10514|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"SPINAL TRAY PEDI 21GA X 2.5"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217.83||||217.83||150.3|64.59
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|AARP [1000]|AARP [100000]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|AETNA [1015]|AETNA [101529]|7.82||||7.82|3.45|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.82||||7.82|2.32|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|BCBS [1155]|BCBS UTHCT [115568]|7.82||||7.82|3.68|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.82||||7.82|3.91|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.82||||7.82|3.91|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.82||||7.82|4.93|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.82||||7.82|2.32|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|CIGNA [1260]|CIGNA GWH [126023]|7.82||||7.82|4.3|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7.82||||7.82|5.4|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.82||||7.82|3.91|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.82||||7.82|3.45|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.82||||7.82|2.32|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.82||||7.82|3.45|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.82||||7.82|2.32|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.82||||7.82|2.32|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7.82||||7.82|5.4|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.82||||7.82|2.32|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|Self-pay|Self-pay|7.82||||7.82|2.73|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.82||||7.82|2.32|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.82||||7.82|2.32|5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.82||||7.82||5.4|2.32
10516|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"POUCH DRAINABLE 12"" 2.25"" SUR-FIT"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.82||||7.82||5.4|2.32
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|AARP [1000]|AARP [100000]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|AETNA [1015]|AETNA [101529]|2.79||||2.79|1.23|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.79||||2.79|0.83|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|BCBS [1155]|BCBS UTHCT [115568]|2.79||||2.79|1.31|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.79||||2.79|1.4|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.79||||2.79|1.4|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.79||||2.79|1.76|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.79||||2.79|0.83|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|CIGNA [1260]|CIGNA GWH [126023]|2.79||||2.79|1.53|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.79||||2.79|1.93|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.79||||2.79|1.4|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.79||||2.79|1.23|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.79||||2.79|0.83|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.79||||2.79|1.23|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.79||||2.79|0.83|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.79||||2.79|0.83|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.79||||2.79|1.93|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.79||||2.79|0.83|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|Self-pay|Self-pay|2.79||||2.79|0.98|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.79||||2.79|0.83|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.79||||2.79|0.83|1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.79||||2.79||1.93|0.83
10518|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDIUM CHAIN TRIGLYCERIDES (MCT) 7.7 KCAL/ML ORAL OIL|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.79||||2.79||1.93|0.83
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|AARP [1000]|AARP [100000]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|AETNA [1015]|AETNA [101529]|101.88||||101.88|44.93|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|101.88||||101.88|30.21|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|BCBS [1155]|BCBS UTHCT [115568]|101.88||||101.88|47.88|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|101.88||||101.88|50.94|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|101.88||||101.88|50.94|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|101.88||||101.88|64.18|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|101.88||||101.88|30.21|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|CIGNA [1260]|CIGNA GWH [126023]|101.88||||101.88|56.03|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|101.88||||101.88|70.3|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|101.88||||101.88|50.94|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|101.88||||101.88|44.93|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|101.88||||101.88|30.21|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|101.88||||101.88|44.93|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|101.88||||101.88|30.21|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|101.88||||101.88|30.21|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|101.88||||101.88|70.3|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|101.88||||101.88|30.21|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|Self-pay|Self-pay|101.88||||101.88|35.66|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|101.88||||101.88|30.21|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|101.88||||101.88|30.21|70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|101.88||||101.88||70.3|30.21
10522|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DUETTE FOLEY TRAY 16FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|101.88||||101.88||70.3|30.21
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|AARP [1000]|AARP [100000]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|AETNA [1015]|AETNA [101529]|129.7||||129.7|57.2|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129.7||||129.7|38.46|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|BCBS [1155]|BCBS UTHCT [115568]|129.7||||129.7|60.96|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129.7||||129.7|64.85|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129.7||||129.7|64.85|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129.7||||129.7|81.71|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129.7||||129.7|38.46|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|CIGNA [1260]|CIGNA GWH [126023]|129.7||||129.7|71.34|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|GROUP PENSION ADMIN [1450]|GPA [145000]|129.7||||129.7|89.5|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|129.7||||129.7|64.85|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129.7||||129.7|57.2|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129.7||||129.7|38.46|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129.7||||129.7|57.2|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129.7||||129.7|38.46|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|129.7||||129.7|38.46|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|PHCS [1780]|PHCS MULTIPLAN [178000]|129.7||||129.7|89.5|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129.7||||129.7|38.46|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|Self-pay|Self-pay|129.7||||129.7|45.39|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|129.7||||129.7|38.46|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129.7||||129.7|38.46|89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129.7||||129.7||89.5|38.46
10523|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FOLEY CATH TRAY DUETTE 16 FR 5CC BALLOON WITH/|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129.7||||129.7||89.5|38.46
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|AARP [1000]|AARP [100000]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|AETNA [1015]|AETNA [101529]|74.36||||74.36|32.79|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.36||||74.36|22.05|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|BCBS [1155]|BCBS UTHCT [115568]|74.36||||74.36|34.95|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.36||||74.36|37.18|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.36||||74.36|37.18|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.36||||74.36|46.85|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.36||||74.36|22.05|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|CIGNA [1260]|CIGNA GWH [126023]|74.36||||74.36|40.9|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74.36||||74.36|51.31|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.36||||74.36|37.18|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.36||||74.36|32.79|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.36||||74.36|22.05|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.36||||74.36|32.79|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.36||||74.36|22.05|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.36||||74.36|22.05|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74.36||||74.36|51.31|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.36||||74.36|22.05|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|Self-pay|Self-pay|74.36||||74.36|26.02|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.36||||74.36|22.05|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.36||||74.36|22.05|51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.36||||74.36||51.31|22.05
10528|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ADMINISTRATION SET BLOOD Y TYPE 130IN NEEDLELESS INJ PORT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.36||||74.36||51.31|22.05
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|AARP [1000]|AARP [100000]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|AETNA [1015]|AETNA [101529]|71.37||||71.37|31.48|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.37||||71.37|21.16|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|BCBS [1155]|BCBS UTHCT [115568]|71.37||||71.37|33.55|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.37||||71.37|35.69|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.37||||71.37|35.69|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.37||||71.37|44.97|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.37||||71.37|21.16|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|CIGNA [1260]|CIGNA GWH [126023]|71.37||||71.37|39.26|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71.37||||71.37|49.25|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71.37||||71.37|35.69|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.37||||71.37|31.48|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.37||||71.37|21.16|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.37||||71.37|31.48|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.37||||71.37|21.16|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|71.37||||71.37|21.16|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71.37||||71.37|49.25|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.37||||71.37|21.16|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|Self-pay|Self-pay|71.37||||71.37|24.98|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71.37||||71.37|21.16|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.37||||71.37|21.16|49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.37||||71.37||49.25|21.16
10531|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR ADULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|AARP [1000]|AARP [100000]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|AETNA [1015]|AETNA [101529]|71.37||||71.37|31.48|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.37||||71.37|21.16|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|BCBS [1155]|BCBS UTHCT [115568]|71.37||||71.37|33.55|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.37||||71.37|35.69|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.37||||71.37|35.69|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.37||||71.37|44.97|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.37||||71.37|21.16|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|CIGNA [1260]|CIGNA GWH [126023]|71.37||||71.37|39.26|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71.37||||71.37|49.25|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71.37||||71.37|35.69|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.37||||71.37|31.48|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.37||||71.37|21.16|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.37||||71.37|31.48|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.37||||71.37|21.16|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|71.37||||71.37|21.16|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71.37||||71.37|49.25|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.37||||71.37|21.16|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|Self-pay|Self-pay|71.37||||71.37|24.98|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71.37||||71.37|21.16|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.37||||71.37|21.16|49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.37||||71.37||49.25|21.16
10532|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OXYGEN SENSOR PEDIATRIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.37||||71.37||49.25|21.16
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|AARP [1000]|AARP [100000]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|AETNA [1015]|AETNA [101529]|16.09||||16.09|7.09|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.09||||16.09|4.77|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|BCBS [1155]|BCBS UTHCT [115568]|16.09||||16.09|7.56|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.09||||16.09|8.04|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.09||||16.09|8.04|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.09||||16.09|10.13|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.09||||16.09|4.77|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|CIGNA [1260]|CIGNA GWH [126023]|16.09||||16.09|8.85|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|16.09||||16.09|11.1|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.09||||16.09|8.04|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.09||||16.09|7.09|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.09||||16.09|4.77|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.09||||16.09|7.09|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.09||||16.09|4.77|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.09||||16.09|4.77|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|16.09||||16.09|11.1|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.09||||16.09|4.77|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|Self-pay|Self-pay|16.09||||16.09|5.63|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.09||||16.09|4.77|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.09||||16.09|4.77|11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.09||||16.09||11.1|4.77
10534|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SPIROMETER INCENTIVE VOLUMETRIC EXERCISER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.09||||16.09||11.1|4.77
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|205.53||||205.53|35.95|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|205.53||||205.53||141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|205.53||||205.53|7.32|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|205.53||||205.53|60.94|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|205.53||||205.53||141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|205.53||||205.53||141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|205.53||||205.53|96.6|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|205.53||||205.53|0|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|205.53||||205.53|102.77|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|205.53||||205.53|129.48|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|205.53||||205.53|60.94|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|205.53||||205.53||141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|205.53||||205.53|113.04|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|205.53||||205.53|141.82|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|205.53||||205.53|2.74|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|205.53||||205.53||141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|205.53||||205.53|7.32|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|205.53||||205.53|60.94|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|205.53||||205.53||141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|205.53||||205.53|7.32|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|205.53||||205.53|60.94|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|205.53||||205.53|60.94|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|205.53||||205.53|141.82|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|205.53||||205.53|60.94|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|205.53||||205.53|71.94|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|205.53||||205.53|60.94|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|205.53||||205.53|60.94|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|205.53||||205.53|35.95|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|205.53||||205.53||141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|205.53||||205.53||141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|205.53||||205.53|35.95|141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|205.53||||205.53||141.82|2.74
10537|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MESNA 100 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|205.53||||205.53||141.82|2.74
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|AARP [1000]|AARP [100000]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|AETNA [1015]|AETNA [101529]|70.94||||70.94|31.28|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70.94||||70.94|21.03|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|BCBS [1155]|BCBS UTHCT [115568]|70.94||||70.94|33.34|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70.94||||70.94|35.47|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70.94||||70.94|35.47|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70.94||||70.94|44.69|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70.94||||70.94|21.03|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|CIGNA [1260]|CIGNA GWH [126023]|70.94||||70.94|39.01|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70.94||||70.94|48.95|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70.94||||70.94|35.47|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70.94||||70.94|31.28|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70.94||||70.94|21.03|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70.94||||70.94|31.28|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70.94||||70.94|21.03|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70.94||||70.94|21.03|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70.94||||70.94|48.95|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70.94||||70.94|21.03|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|Self-pay|Self-pay|70.94||||70.94|24.83|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70.94||||70.94|21.03|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70.94||||70.94|21.03|48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70.94||||70.94||48.95|21.03
10541|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING FOAM ALLEVYN LIFE 8.25 X 8.25 W/ 6 X 6 PAD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70.94||||70.94||48.95|21.03
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|AARP [1000]|AARP [100000]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|AETNA [1015]|AETNA [101529]|85.27||||85.27|37.6|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|85.27||||85.27|25.28|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|BCBS [1155]|BCBS UTHCT [115568]|85.27||||85.27|40.08|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|85.27||||85.27|42.64|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|85.27||||85.27|42.64|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|85.27||||85.27|53.72|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|85.27||||85.27|25.28|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|CIGNA [1260]|CIGNA GWH [126023]|85.27||||85.27|46.9|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|85.27||||85.27|58.84|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|85.27||||85.27|42.64|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|85.27||||85.27|37.6|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|85.27||||85.27|25.28|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|85.27||||85.27|37.6|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|85.27||||85.27|25.28|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|85.27||||85.27|25.28|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|85.27||||85.27|58.84|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|85.27||||85.27|25.28|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|Self-pay|Self-pay|85.27||||85.27|29.84|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|85.27||||85.27|25.28|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|85.27||||85.27|25.28|58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|85.27||||85.27||58.84|25.28
10543|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FOLEY SILICONE 18 FR 5CC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|85.27||||85.27||58.84|25.28
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.41||||0.41|0.18|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.41||||0.41|0.12|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.41||||0.41|0.19|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.41||||0.41|0.21|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.41||||0.41|0.21|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.41||||0.41|0.26|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.41||||0.41|0.12|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.41||||0.41|0.23|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.41||||0.41|0.28|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.41||||0.41|0.21|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.41||||0.41|0.18|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.41||||0.41|0.12|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.41||||0.41|0.18|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.41||||0.41|0.12|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.41||||0.41|0.12|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.41||||0.41|0.28|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.41||||0.41|0.12|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.41||||0.41|0.14|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.41||||0.41|0.12|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.41||||0.41|0.12|255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.41||||0.41||255.06|0.12
10544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.41||||0.41||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|AARP [1000]|AARP [100000]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|AETNA [1015]|AETNA [101529]|369.66||||369.66|163.02|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|369.66||||369.66|109.6|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|BCBS [1155]|BCBS UTHCT [115568]|369.66||||369.66|173.74|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|369.66||||369.66|184.83|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|369.66||||369.66|184.83|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|369.66||||369.66|232.88|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|369.66||||369.66|109.6|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|CIGNA [1260]|CIGNA GWH [126023]|369.66||||369.66|203.31|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|369.66||||369.66|255.06|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|369.66||||369.66|184.83|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|369.66||||369.66|163.02|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|369.66||||369.66|109.6|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|369.66||||369.66|163.02|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|369.66||||369.66|109.6|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|369.66||||369.66|109.6|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|369.66||||369.66|255.06|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|369.66||||369.66|109.6|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|Self-pay|Self-pay|369.66||||369.66|129.38|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|369.66||||369.66|109.6|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|369.66||||369.66|109.6|255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|369.66||||369.66||255.06|0.12
10544|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER AIRWAY EXCHANGER 14 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|369.66||||369.66||255.06|0.12
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AARP [1000]|AARP [100000]|4198.15||||4198.15|1277.4|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4198.15||||4198.15|1284.05|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|4198.15||||4198.15|2865.6|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4198.15||||4198.15|1244.75|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4198.15||||4198.15|1271.34|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4198.15||||4198.15|1271.34|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|4198.15||||4198.15|1973.13|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4198.15||||4198.15|0|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4198.15||||4198.15|2099.08|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4198.15||||4198.15|2644.83|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4198.15||||4198.15|1244.75|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4198.15||||4198.15|1271.34|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|4198.15||||4198.15|2099.08|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4198.15||||4198.15|2896.72|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4198.15||||4198.15|25.14|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4198.15||||4198.15|1271.34|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4198.15||||4198.15|2865.6|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4198.15||||4198.15|1244.75|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4198.15||||4198.15|1271.34|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4198.15||||4198.15|2865.6|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4198.15||||4198.15|1244.75|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4198.15||||4198.15|1244.75|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4198.15||||4198.15|2896.72|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4198.15||||4198.15|1244.75|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|Self-pay|Self-pay|4198.15||||4198.15|1469.35|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4198.15||||4198.15|1244.75|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4198.15||||4198.15|1244.75|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4198.15||||4198.15|1277.4|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4198.15||||4198.15|1271.34|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4198.15||||4198.15|1271.34|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4198.15||||4198.15|1277.4|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4198.15||||4198.15|1271.34|2896.72|25.14
105502|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 60 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4198.15||||4198.15|2542.68|2896.72|25.14
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|AARP [1000]|AARP [100000]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|AETNA [1015]|AETNA [101529]|1235.21||||1235.21|544.73|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1235.21||||1235.21|366.24|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|BCBS [1155]|BCBS UTHCT [115568]|1235.21||||1235.21|580.55|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1235.21||||1235.21|617.6|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1235.21||||1235.21|617.6|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1235.21||||1235.21|778.18|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1235.21||||1235.21|366.24|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|CIGNA [1260]|CIGNA GWH [126023]|1235.21||||1235.21|679.36|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1235.21||||1235.21|852.29|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1235.21||||1235.21|617.6|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1235.21||||1235.21|544.73|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1235.21||||1235.21|366.24|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1235.21||||1235.21|544.73|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1235.21||||1235.21|366.24|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1235.21||||1235.21|366.24|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1235.21||||1235.21|852.29|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1235.21||||1235.21|366.24|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|Self-pay|Self-pay|1235.21||||1235.21|432.32|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1235.21||||1235.21|366.24|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1235.21||||1235.21|366.24|852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1235.21||||1235.21||852.29|366.24
10551|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER PICC DUAL LUMEN 4 FR SHERLOCK 3 CG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1235.21||||1235.21||852.29|366.24
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.29||||1.29|0.57|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.29||||1.29|0.38|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.29||||1.29|0.61|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.29||||1.29|0.65|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.29||||1.29|0.65|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.29||||1.29|0.81|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.29||||1.29|0.38|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.29||||1.29|0.71|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.29||||1.29|0.89|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.29||||1.29|0.65|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.29||||1.29|0.57|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.29||||1.29|0.38|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.29||||1.29|0.57|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.29||||1.29|0.38|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.29||||1.29|0.38|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.29||||1.29|0.89|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.29||||1.29|0.38|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.29||||1.29|0.45|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.29||||1.29|0.38|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.29||||1.29|0.38|0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.29||||1.29||0.89|0.38
10552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHIMAZOLE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.29||||1.29||0.89|0.38
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|AARP [1000]|AARP [100000]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|AETNA [1015]|AETNA [101529]|64.17||||64.17|28.3|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64.17||||64.17|19.03|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|BCBS [1155]|BCBS UTHCT [115568]|64.17||||64.17|30.16|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64.17||||64.17|32.08|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64.17||||64.17|32.08|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64.17||||64.17|40.43|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64.17||||64.17|19.03|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|CIGNA [1260]|CIGNA GWH [126023]|64.17||||64.17|35.29|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|64.17||||64.17|44.28|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|64.17||||64.17|32.08|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64.17||||64.17|28.3|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64.17||||64.17|19.03|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64.17||||64.17|28.3|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64.17||||64.17|19.03|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|64.17||||64.17|19.03|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|64.17||||64.17|44.28|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64.17||||64.17|19.03|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|Self-pay|Self-pay|64.17||||64.17|22.46|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|64.17||||64.17|19.03|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64.17||||64.17|19.03|44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64.17||||64.17||44.28|19.03
10553|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE HANDLE DISP GREENLINE/D LED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64.17||||64.17||44.28|19.03
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|AARP [1000]|AARP [100000]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|AETNA [1015]|AETNA [101529]|46.15||||46.15|20.35|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.15||||46.15|13.68|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|BCBS [1155]|BCBS UTHCT [115568]|46.15||||46.15|21.69|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.15||||46.15|23.07|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.15||||46.15|23.07|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.15||||46.15|29.07|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.15||||46.15|13.68|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|CIGNA [1260]|CIGNA GWH [126023]|46.15||||46.15|25.38|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|46.15||||46.15|31.84|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|46.15||||46.15|23.07|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.15||||46.15|20.35|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.15||||46.15|13.68|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.15||||46.15|20.35|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.15||||46.15|13.68|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|46.15||||46.15|13.68|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|46.15||||46.15|31.84|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.15||||46.15|13.68|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|Self-pay|Self-pay|46.15||||46.15|16.15|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|46.15||||46.15|13.68|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.15||||46.15|13.68|31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.15||||46.15||31.84|13.68
10554|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 3 FIBER OPTIC DISP SS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|AARP [1000]|AARP [100000]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|AETNA [1015]|AETNA [101529]|46.15||||46.15|20.35|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.15||||46.15|13.68|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|BCBS [1155]|BCBS UTHCT [115568]|46.15||||46.15|21.69|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.15||||46.15|23.07|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.15||||46.15|23.07|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.15||||46.15|29.07|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.15||||46.15|13.68|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|CIGNA [1260]|CIGNA GWH [126023]|46.15||||46.15|25.38|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|46.15||||46.15|31.84|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|46.15||||46.15|23.07|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.15||||46.15|20.35|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.15||||46.15|13.68|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.15||||46.15|20.35|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.15||||46.15|13.68|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|46.15||||46.15|13.68|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|46.15||||46.15|31.84|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.15||||46.15|13.68|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|Self-pay|Self-pay|46.15||||46.15|16.15|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|46.15||||46.15|13.68|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.15||||46.15|13.68|31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.15||||46.15||31.84|13.68
10555|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGOSCOPE BLADE MACINTOSH 4 FIBER OPTIC DISP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.15||||46.15||31.84|13.68
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|12.44||||12.44|5.49|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.44||||12.44|3.69|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|12.44||||12.44|5.85|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.44||||12.44|6.22|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.44||||12.44|6.22|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.44||||12.44|7.84|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.44||||12.44|3.69|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|12.44||||12.44|6.84|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.44||||12.44|8.58|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.44||||12.44|6.22|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.44||||12.44|5.49|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.44||||12.44|3.69|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.44||||12.44|5.49|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.44||||12.44|3.69|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.44||||12.44|3.69|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.44||||12.44|8.58|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.44||||12.44|3.69|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|Self-pay|Self-pay|12.44||||12.44|4.35|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.44||||12.44|3.69|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.44||||12.44|3.69|8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.44||||12.44||8.58|3.69
105633|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.44||||12.44||8.58|3.69
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|16.87||||16.87|7.44|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.87||||16.87|5|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|16.87||||16.87|7.93|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.87||||16.87|8.44|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.87||||16.87|8.44|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.87||||16.87|10.63|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.87||||16.87|5|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|16.87||||16.87|9.28|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.87||||16.87|11.64|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.87||||16.87|8.44|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.87||||16.87|7.44|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.87||||16.87|5|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.87||||16.87|7.44|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.87||||16.87|5|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.87||||16.87|5|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.87||||16.87|11.64|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.87||||16.87|5|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|Self-pay|Self-pay|16.87||||16.87|5.9|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.87||||16.87|5|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.87||||16.87|5|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.87||||16.87||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|25.58||||25.58|11.28|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.58||||25.58|7.58|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|25.58||||25.58|12.02|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.58||||25.58|12.79|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.58||||25.58|12.79|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.58||||25.58|16.12|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.58||||25.58|7.58|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|25.58||||25.58|14.07|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|25.58||||25.58|17.65|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25.58||||25.58|12.79|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.58||||25.58|11.28|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.58||||25.58|7.58|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.58||||25.58|11.28|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.58||||25.58|7.58|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|25.58||||25.58|7.58|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.58||||25.58|17.65|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.58||||25.58|7.58|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|Self-pay|Self-pay|25.58||||25.58|8.95|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25.58||||25.58|7.58|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.58||||25.58|7.58|17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.58||||25.58||17.65|5
105634|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.58||||25.58||17.65|5
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|14.14||||14.14|6.24|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.14||||14.14|4.19|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|14.14||||14.14|6.65|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.14||||14.14|7.07|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.14||||14.14|7.07|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.14||||14.14|8.91|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.14||||14.14|4.19|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|14.14||||14.14|7.78|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.14||||14.14|9.76|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.14||||14.14|7.07|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.14||||14.14|6.24|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.14||||14.14|4.19|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.14||||14.14|6.24|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.14||||14.14|4.19|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.14||||14.14|4.19|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.14||||14.14|9.76|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.14||||14.14|4.19|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|Self-pay|Self-pay|14.14||||14.14|4.95|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.14||||14.14|4.19|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.14||||14.14|4.19|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.14||||14.14||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|5.68||||5.68|2.5|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.68||||5.68|1.68|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|5.68||||5.68|2.67|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.68||||5.68|2.84|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.68||||5.68|2.84|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.68||||5.68|3.58|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.68||||5.68|1.68|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|5.68||||5.68|3.12|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.68||||5.68|3.92|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.68||||5.68|2.84|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.68||||5.68|2.5|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.68||||5.68|1.68|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.68||||5.68|2.5|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.68||||5.68|1.68|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.68||||5.68|1.68|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.68||||5.68|3.92|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.68||||5.68|1.68|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|Self-pay|Self-pay|5.68||||5.68|1.99|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.68||||5.68|1.68|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.68||||5.68|1.68|9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.68||||5.68||9.76|1.68
105640|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.68||||5.68||9.76|1.68
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|AARP [1000]|AARP [100000]|25059.41||||25059.41|12529.71|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25059.41||||25059.41|11453.22|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|AETNA [1015]|AETNA [101529]|25059.41||||25059.41|25059.41|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25059.41||||25059.41|7430.12|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25059.41||||25059.41|11339.82|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25059.41||||25059.41|11339.82|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|BCBS [1155]|BCBS UTHCT [115568]|25059.41||||25059.41|11777.92|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25059.41||||25059.41|0|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25059.41||||25059.41|12529.71|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25059.41||||25059.41|15787.43|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25059.41||||25059.41|7430.12|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25059.41||||25059.41|11339.82|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|CIGNA [1260]|CIGNA GWH [126023]|25059.41||||25059.41|12529.71|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|25059.41||||25059.41|17290.99|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25059.41||||25059.41|231.06|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25059.41||||25059.41|11339.82|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25059.41||||25059.41|25059.41|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25059.41||||25059.41|7430.12|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25059.41||||25059.41|11339.82|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25059.41||||25059.41|25059.41|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25059.41||||25059.41|7430.12|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|25059.41||||25059.41|7430.12|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25059.41||||25059.41|17290.99|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25059.41||||25059.41|7430.12|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|Self-pay|Self-pay|25059.41||||25059.41|8770.79|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25059.41||||25059.41|7430.12|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25059.41||||25059.41|7430.12|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25059.41||||25059.41|12529.71|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25059.41||||25059.41|11339.82|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25059.41||||25059.41|11339.82|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25059.41||||25059.41|12529.71|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25059.41||||25059.41|11339.82|25059.41|231.06
105644|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CABAZITAXEL 10 MG/ML (FINAL CONC) INTRAVENOUS SOLUTION|6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25059.41||||25059.41|22679.64|25059.41|231.06
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|AARP [1000]|AARP [100000]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|AETNA [1015]|AETNA [101529]|1754.64||||1754.64|773.8|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1754.64||||1754.64|520.25|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|BCBS [1155]|BCBS UTHCT [115568]|1754.64||||1754.64|824.68|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1754.64||||1754.64|877.32|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1754.64||||1754.64|877.32|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1754.64||||1754.64|1105.42|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1754.64||||1754.64|520.25|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|CIGNA [1260]|CIGNA GWH [126023]|1754.64||||1754.64|965.05|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1754.64||||1754.64|1210.7|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1754.64||||1754.64|877.32|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1754.64||||1754.64|773.8|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1754.64||||1754.64|520.25|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1754.64||||1754.64|773.8|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1754.64||||1754.64|520.25|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1754.64||||1754.64|520.25|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1754.64||||1754.64|1210.7|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1754.64||||1754.64|520.25|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|Self-pay|Self-pay|1754.64||||1754.64|614.12|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1754.64||||1754.64|520.25|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1754.64||||1754.64|520.25|1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1754.64||||1754.64||1210.7|520.25
10565|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP RESOLUTION 360 235 CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1754.64||||1754.64||1210.7|520.25
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|AARP [1000]|AARP [100000]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|AETNA [1015]|AETNA [101529]|907.5||||907.5|400.21|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|907.5||||907.5|269.07|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|BCBS [1155]|BCBS UTHCT [115568]|907.5||||907.5|426.53|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|907.5||||907.5|453.75|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|907.5||||907.5|453.75|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|907.5||||907.5|571.73|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|907.5||||907.5|269.07|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|CIGNA [1260]|CIGNA GWH [126023]|907.5||||907.5|499.13|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|GROUP PENSION ADMIN [1450]|GPA [145000]|907.5||||907.5|626.18|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|907.5||||907.5|453.75|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|907.5||||907.5|400.21|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|907.5||||907.5|269.07|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|907.5||||907.5|400.21|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|907.5||||907.5|269.07|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|907.5||||907.5|269.07|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|PHCS [1780]|PHCS MULTIPLAN [178000]|907.5||||907.5|626.18|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|907.5||||907.5|269.07|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|Self-pay|Self-pay|907.5||||907.5|317.62|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|907.5||||907.5|269.07|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|907.5||||907.5|269.07|626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|907.5||||907.5||626.18|269.07
10572|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE 12-15MM 8CM F/G|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|907.5||||907.5||626.18|269.07
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|0.45||||0.45|0.2|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.45||||0.45|0.13|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.45||||0.45|0.21|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.45||||0.45|0.23|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.45||||0.45|0.23|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.45||||0.45|0.28|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.45||||0.45|0.13|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.45||||0.45|0.25|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.45||||0.45|0.31|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.45||||0.45|0.23|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.45||||0.45|0.2|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.45||||0.45|0.13|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.45||||0.45|0.2|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.45||||0.45|0.13|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.45||||0.45|0.13|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.45||||0.45|0.31|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.45||||0.45|0.13|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|0.45||||0.45|0.16|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.45||||0.45|0.13|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.45||||0.45|0.13|0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.45||||0.45||0.31|0.13
105730|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM 71.5 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.45||||0.45||0.31|0.13
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AARP [1000]|AARP [100000]|136.34||||136.34|119.92|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136.34||||136.34||129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AETNA [1015]|AETNA [101529]|136.34||||136.34|129.02|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136.34||||136.34|40.42|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136.34||||136.34||129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136.34||||136.34||129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BCBS UTHCT [115568]|136.34||||136.34|64.08|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136.34||||136.34|0|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136.34||||136.34|68.17|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136.34||||136.34|85.89|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136.34||||136.34|40.42|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136.34||||136.34||129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|CIGNA [1260]|CIGNA GWH [126023]|136.34||||136.34|74.99|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|136.34||||136.34|94.07|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|136.34||||136.34|6.86|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136.34||||136.34||129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136.34||||136.34|129.02|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136.34||||136.34|40.42|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136.34||||136.34||129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136.34||||136.34|129.02|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136.34||||136.34|40.42|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|136.34||||136.34|40.42|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|136.34||||136.34|94.07|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136.34||||136.34|40.42|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|Self-pay|Self-pay|136.34||||136.34|47.72|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|136.34||||136.34|40.42|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136.34||||136.34|40.42|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136.34||||136.34|119.92|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|136.34||||136.34||129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|136.34||||136.34||129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136.34||||136.34|119.92|129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136.34||||136.34||129.02|6.86
10577|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 1,000 MG INTRAVENOUS SOLUTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136.34||||136.34||129.02|6.86
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|AARP [1000]|AARP [100000]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|AETNA [1015]|AETNA [101529]|907.5||||907.5|400.21|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|907.5||||907.5|269.07|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|BCBS [1155]|BCBS UTHCT [115568]|907.5||||907.5|426.53|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|907.5||||907.5|453.75|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|907.5||||907.5|453.75|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|907.5||||907.5|571.73|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|907.5||||907.5|269.07|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|CIGNA [1260]|CIGNA GWH [126023]|907.5||||907.5|499.13|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|907.5||||907.5|626.18|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|907.5||||907.5|453.75|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|907.5||||907.5|400.21|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|907.5||||907.5|269.07|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|907.5||||907.5|400.21|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|907.5||||907.5|269.07|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|907.5||||907.5|269.07|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|907.5||||907.5|626.18|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|907.5||||907.5|269.07|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|Self-pay|Self-pay|907.5||||907.5|317.62|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|907.5||||907.5|269.07|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|907.5||||907.5|269.07|626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|907.5||||907.5||626.18|269.07
10578|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO15-18MM 240CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|907.5||||907.5||626.18|269.07
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|18.85||||18.85|5.86|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.85||||18.85||13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|18.85||||18.85|10.85|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.85||||18.85|5.59|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.85||||18.85||13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.85||||18.85||13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|18.85||||18.85|8.86|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.85||||18.85|0|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.85||||18.85|9.43|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.85||||18.85|11.88|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.85||||18.85|5.59|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.85||||18.85||13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|18.85||||18.85|10.37|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.85||||18.85|13.01|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.85||||18.85|5.48|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.85||||18.85||13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.85||||18.85|10.85|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.85||||18.85|5.59|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.85||||18.85||13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.85||||18.85|10.85|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.85||||18.85|5.59|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.85||||18.85|5.59|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.85||||18.85|13.01|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.85||||18.85|5.59|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|Self-pay|Self-pay|18.85||||18.85|6.6|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.85||||18.85|5.59|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.85||||18.85|5.59|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.85||||18.85|5.86|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.85||||18.85||13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.85||||18.85||13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.85||||18.85|5.86|13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.85||||18.85||13.01|5.48
10580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 40 MG SOLUTION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.85||||18.85||13.01|5.48
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|75.27||||75.27|59.96|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75.27||||75.27||64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|75.27||||75.27|64.51|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75.27||||75.27|22.32|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75.27||||75.27||64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75.27||||75.27||64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|75.27||||75.27|35.38|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75.27||||75.27|0|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75.27||||75.27|37.64|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75.27||||75.27|47.42|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75.27||||75.27|22.32|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75.27||||75.27||64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|75.27||||75.27|41.4|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|75.27||||75.27|51.94|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|75.27||||75.27|6.86|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75.27||||75.27||64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75.27||||75.27|64.51|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75.27||||75.27|22.32|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75.27||||75.27||64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75.27||||75.27|64.51|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75.27||||75.27|22.32|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|75.27||||75.27|22.32|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|75.27||||75.27|51.94|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75.27||||75.27|22.32|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|75.27||||75.27|26.34|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|75.27||||75.27|22.32|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75.27||||75.27|22.32|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75.27||||75.27|59.96|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|75.27||||75.27||64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|75.27||||75.27||64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75.27||||75.27|59.96|64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75.27||||75.27||64.51|6.86
10581|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75.27||||75.27||64.51|6.86
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|AARP [1000]|AARP [100000]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|AETNA [1015]|AETNA [101529]|831.88||||831.88|366.86|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|831.88||||831.88|246.65|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|BCBS [1155]|BCBS UTHCT [115568]|831.88||||831.88|390.98|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|831.88||||831.88|415.94|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|831.88||||831.88|415.94|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|831.88||||831.88|524.08|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|831.88||||831.88|246.65|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|CIGNA [1260]|CIGNA GWH [126023]|831.88||||831.88|457.53|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|GROUP PENSION ADMIN [1450]|GPA [145000]|831.88||||831.88|573.99|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|831.88||||831.88|415.94|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|831.88||||831.88|366.86|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|831.88||||831.88|246.65|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|831.88||||831.88|366.86|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|831.88||||831.88|246.65|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|831.88||||831.88|246.65|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|PHCS [1780]|PHCS MULTIPLAN [178000]|831.88||||831.88|573.99|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|831.88||||831.88|246.65|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|Self-pay|Self-pay|831.88||||831.88|291.16|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|831.88||||831.88|246.65|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|831.88||||831.88|246.65|573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|831.88||||831.88||573.99|246.65
10583|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BAND,SPEEDBAND SUPERVIEW SUP 7|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|831.88||||831.88||573.99|246.65
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.15||||5.15|2.27|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.15||||5.15|1.53|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.15||||5.15|2.42|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.15||||5.15|2.58|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.15||||5.15|2.58|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.15||||5.15|3.24|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.15||||5.15|1.53|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.15||||5.15|2.83|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.15||||5.15|3.55|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.15||||5.15|2.58|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.15||||5.15|2.27|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.15||||5.15|1.53|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.15||||5.15|2.27|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.15||||5.15|1.53|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.15||||5.15|1.53|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.15||||5.15|3.55|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.15||||5.15|1.53|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|5.15||||5.15|1.8|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.15||||5.15|1.53|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.15||||5.15|1.53|3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.15||||5.15||3.55|1.53
10587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.15||||5.15||3.55|1.53
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.85||||5.85|2.58|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.85||||5.85|1.73|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.85||||5.85|2.75|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.85||||5.85|2.93|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.85||||5.85|2.93|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.85||||5.85|3.69|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.85||||5.85|1.73|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.85||||5.85|3.22|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.85||||5.85|4.04|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.85||||5.85|2.93|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.85||||5.85|2.58|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.85||||5.85|1.73|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.85||||5.85|2.58|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.85||||5.85|1.73|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.85||||5.85|1.73|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.85||||5.85|4.04|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.85||||5.85|1.73|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|5.85||||5.85|2.05|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.85||||5.85|1.73|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.85||||5.85|1.73|4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.85||||5.85||4.04|1.73
10588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOLAZONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.85||||5.85||4.04|1.73
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AARP [1000]|AARP [100000]|24.62||||24.62|17.24|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.62||||24.62||17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AETNA [1015]|AETNA [101529]|24.62||||24.62|6.62|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.62||||24.62|7.3|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.62||||24.62||17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.62||||24.62||17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS [1155]|BCBS UTHCT [115568]|24.62||||24.62|11.57|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.62||||24.62|0|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.62||||24.62|12.31|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.62||||24.62|15.51|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.62||||24.62|7.3|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.62||||24.62||17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|CIGNA [1260]|CIGNA GWH [126023]|24.62||||24.62|13.54|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.62||||24.62|16.99|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.62||||24.62|1|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.62||||24.62||17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.62||||24.62|6.62|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.62||||24.62|7.3|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.62||||24.62||17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.62||||24.62|6.62|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.62||||24.62|7.3|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.62||||24.62|7.3|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.62||||24.62|16.99|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.62||||24.62|7.3|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|Self-pay|Self-pay|24.62||||24.62|8.62|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.62||||24.62|7.3|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.62||||24.62|7.3|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.62||||24.62|17.24|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.62||||24.62||17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.62||||24.62||17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.62||||24.62|17.24|17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.62||||24.62||17.24|1
105900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 40 MG/0.4 ML SUBCUTANEOUS SYRINGE|0.4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.62||||24.62||17.24|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AARP [1000]|AARP [100000]|37.2||||37.2|34.48|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.2||||37.2||34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA [101529]|37.2||||37.2|13.25|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.2||||37.2|11.03|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.2||||37.2||34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.2||||37.2||34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BCBS UTHCT [115568]|37.2||||37.2|17.48|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.2||||37.2|0|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.2||||37.2|18.6|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.2||||37.2|23.44|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.2||||37.2|11.03|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.2||||37.2||34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA GWH [126023]|37.2||||37.2|20.46|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|37.2||||37.2|25.67|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|37.2||||37.2|1|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.2||||37.2||34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.2||||37.2|13.25|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.2||||37.2|11.03|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.2||||37.2||34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.2||||37.2|13.25|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.2||||37.2|11.03|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|37.2||||37.2|11.03|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|37.2||||37.2|25.67|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.2||||37.2|11.03|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|37.2||||37.2|13.02|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|37.2||||37.2|11.03|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.2||||37.2|11.03|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.2||||37.2|34.48|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|37.2||||37.2||34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|37.2||||37.2||34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.2||||37.2|34.48|34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.2||||37.2||34.48|1
105902|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 80 MG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.2||||37.2||34.48|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AARP [1000]|AARP [100000]|46.5||||46.5|43.1|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.5||||46.5||43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|46.5||||46.5|16.56|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.5||||46.5|13.79|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.5||||46.5||43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.5||||46.5||43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|46.5||||46.5|21.86|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.5||||46.5|0|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.5||||46.5|23.25|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.5||||46.5|29.3|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.5||||46.5|13.79|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.5||||46.5||43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|46.5||||46.5|25.58|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|46.5||||46.5|32.09|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|46.5||||46.5|1|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.5||||46.5||43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.5||||46.5|16.56|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.5||||46.5|13.79|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.5||||46.5||43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.5||||46.5|16.56|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.5||||46.5|13.79|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|46.5||||46.5|13.79|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|46.5||||46.5|32.09|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.5||||46.5|13.79|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|Self-pay|Self-pay|46.5||||46.5|16.27|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|46.5||||46.5|13.79|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.5||||46.5|13.79|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.5||||46.5|43.1|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|46.5||||46.5||43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|46.5||||46.5||43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.5||||46.5|43.1|43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.5||||46.5||43.1|1
105903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.5||||46.5||43.1|1
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|AARP [1000]|AARP [100000]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|AETNA [1015]|AETNA [101529]|907.5||||907.5|400.21|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|907.5||||907.5|269.07|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|BCBS [1155]|BCBS UTHCT [115568]|907.5||||907.5|426.53|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|907.5||||907.5|453.75|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|907.5||||907.5|453.75|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|907.5||||907.5|571.73|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|907.5||||907.5|269.07|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|CIGNA [1260]|CIGNA GWH [126023]|907.5||||907.5|499.13|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|907.5||||907.5|626.18|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|907.5||||907.5|453.75|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|907.5||||907.5|400.21|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|907.5||||907.5|269.07|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|907.5||||907.5|400.21|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|907.5||||907.5|269.07|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|907.5||||907.5|269.07|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|907.5||||907.5|626.18|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|907.5||||907.5|269.07|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|Self-pay|Self-pay|907.5||||907.5|317.62|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|907.5||||907.5|269.07|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|907.5||||907.5|269.07|626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|907.5||||907.5||626.18|269.07
10591|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|WIREGUIDE CRE PRO18-20MM 240CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|907.5||||907.5||626.18|269.07
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|AARP [1000]|AARP [100000]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|AETNA [1015]|AETNA [101529]|401.48||||401.48|177.05|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|401.48||||401.48|119.04|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|BCBS [1155]|BCBS UTHCT [115568]|401.48||||401.48|188.69|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|401.48||||401.48|200.74|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|401.48||||401.48|200.74|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|401.48||||401.48|252.93|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|401.48||||401.48|119.04|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|CIGNA [1260]|CIGNA GWH [126023]|401.48||||401.48|220.81|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|401.48||||401.48|277.02|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|401.48||||401.48|200.74|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|401.48||||401.48|177.05|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|401.48||||401.48|119.04|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|401.48||||401.48|177.05|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|401.48||||401.48|119.04|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|401.48||||401.48|119.04|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|401.48||||401.48|277.02|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|401.48||||401.48|119.04|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|Self-pay|Self-pay|401.48||||401.48|140.52|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|401.48||||401.48|119.04|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|401.48||||401.48|119.04|277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|401.48||||401.48||277.02|119.04
10593|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SNARE,CAPTIVATOR COLD 10MM RND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|401.48||||401.48||277.02|119.04
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.01||||4.01|1.77|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.01||||4.01|1.19|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|4.01||||4.01|1.88|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.01||||4.01|2.01|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.01||||4.01|2.01|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.01||||4.01|2.53|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.01||||4.01|1.19|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|4.01||||4.01|2.21|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.01||||4.01|2.77|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.01||||4.01|2.01|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.01||||4.01|1.77|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.01||||4.01|1.19|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.01||||4.01|1.77|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.01||||4.01|1.19|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.01||||4.01|1.19|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.01||||4.01|2.77|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.01||||4.01|1.19|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.01||||4.01|1.4|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.01||||4.01|1.19|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.01||||4.01|1.19|2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.01||||4.01||2.77|1.19
10595|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEXILETINE 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.01||||4.01||2.77|1.19
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|AARP [1000]|AARP [100000]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|AETNA [1015]|AETNA [101529]|17.58||||17.58|7.75|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.58||||17.58|5.21|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|BCBS [1155]|BCBS UTHCT [115568]|17.58||||17.58|8.26|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.58||||17.58|8.79|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.58||||17.58|8.79|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.58||||17.58|11.08|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.58||||17.58|5.21|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|CIGNA [1260]|CIGNA GWH [126023]|17.58||||17.58|9.67|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|17.58||||17.58|12.13|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.58||||17.58|8.79|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.58||||17.58|7.75|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.58||||17.58|5.21|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.58||||17.58|7.75|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.58||||17.58|5.21|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.58||||17.58|5.21|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|17.58||||17.58|12.13|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.58||||17.58|5.21|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|Self-pay|Self-pay|17.58||||17.58|6.15|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.58||||17.58|5.21|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.58||||17.58|5.21|12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.58||||17.58||12.13|5.21
10598|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACCESSORY INTRODUCER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.58||||17.58||12.13|5.21
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|AARP [1000]|AARP [100000]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|AETNA [1015]|AETNA [101529]|34.46||||34.46|15.2|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.46||||34.46|10.22|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|BCBS [1155]|BCBS UTHCT [115568]|34.46||||34.46|16.19|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.46||||34.46|17.23|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.46||||34.46|17.23|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.46||||34.46|21.71|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.46||||34.46|10.22|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|CIGNA [1260]|CIGNA GWH [126023]|34.46||||34.46|18.95|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34.46||||34.46|23.78|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34.46||||34.46|17.23|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.46||||34.46|15.2|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.46||||34.46|10.22|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.46||||34.46|15.2|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.46||||34.46|10.22|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34.46||||34.46|10.22|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34.46||||34.46|23.78|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.46||||34.46|10.22|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|Self-pay|Self-pay|34.46||||34.46|12.06|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34.46||||34.46|10.22|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.46||||34.46|10.22|23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.46||||34.46||23.78|10.22
10604|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 MONOCRYL PS-2 REV CUTTING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.46||||34.46||23.78|10.22
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|AARP [1000]|AARP [100000]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|AETNA [1015]|AETNA [101529]|29.53||||29.53|13.02|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.53||||29.53|8.76|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|BCBS [1155]|BCBS UTHCT [115568]|29.53||||29.53|13.88|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.53||||29.53|14.77|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.53||||29.53|14.77|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.53||||29.53|18.61|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.53||||29.53|8.76|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|CIGNA [1260]|CIGNA GWH [126023]|29.53||||29.53|16.24|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|GROUP PENSION ADMIN [1450]|GPA [145000]|29.53||||29.53|20.38|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29.53||||29.53|14.77|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.53||||29.53|13.02|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.53||||29.53|8.76|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.53||||29.53|13.02|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.53||||29.53|8.76|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|29.53||||29.53|8.76|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|PHCS [1780]|PHCS MULTIPLAN [178000]|29.53||||29.53|20.38|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.53||||29.53|8.76|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|Self-pay|Self-pay|29.53||||29.53|10.33|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29.53||||29.53|8.76|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.53||||29.53|8.76|20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.53||||29.53||20.38|8.76
10605|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 VICRYL PLUS-A/B PS-2|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.53||||29.53||20.38|8.76
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|AARP [1000]|AARP [100000]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|AETNA [1015]|AETNA [101529]|22.06||||22.06|9.73|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.06||||22.06|6.54|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|BCBS [1155]|BCBS UTHCT [115568]|22.06||||22.06|10.37|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.06||||22.06|11.03|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.06||||22.06|11.03|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.06||||22.06|13.9|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.06||||22.06|6.54|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|CIGNA [1260]|CIGNA GWH [126023]|22.06||||22.06|12.13|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|22.06||||22.06|15.22|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22.06||||22.06|11.03|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.06||||22.06|9.73|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.06||||22.06|6.54|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.06||||22.06|9.73|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.06||||22.06|6.54|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|22.06||||22.06|6.54|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|22.06||||22.06|15.22|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.06||||22.06|6.54|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|Self-pay|Self-pay|22.06||||22.06|7.72|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22.06||||22.06|6.54|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.06||||22.06|6.54|15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.06||||22.06||15.22|6.54
10606|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4.0 NYLON PS-2 REV CUTTING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.06||||22.06||15.22|6.54
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|AARP [1000]|AARP [100000]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|AETNA [1015]|AETNA [101529]|19.51||||19.51|8.61|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.51||||19.51|5.79|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|BCBS [1155]|BCBS UTHCT [115568]|19.51||||19.51|9.17|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.51||||19.51|9.76|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.51||||19.51|9.76|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.51||||19.51|12.29|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.51||||19.51|5.79|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|CIGNA [1260]|CIGNA GWH [126023]|19.51||||19.51|10.73|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|19.51||||19.51|13.46|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.51||||19.51|9.76|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.51||||19.51|8.61|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.51||||19.51|5.79|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.51||||19.51|8.61|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.51||||19.51|5.79|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.51||||19.51|5.79|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|19.51||||19.51|13.46|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.51||||19.51|5.79|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|Self-pay|Self-pay|19.51||||19.51|6.83|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.51||||19.51|5.79|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.51||||19.51|5.79|13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.51||||19.51||13.46|5.79
10607|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5.0 NYLON NON ABS REV CUTTING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.51||||19.51||13.46|5.79
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|110.83||||110.83|48.88|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|110.83||||110.83|32.86|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|110.83||||110.83|52.09|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|110.83||||110.83|55.42|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|110.83||||110.83|55.42|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|110.83||||110.83|69.82|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|110.83||||110.83|32.86|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|110.83||||110.83|60.96|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|110.83||||110.83|76.47|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|110.83||||110.83|55.42|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|110.83||||110.83|48.88|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|110.83||||110.83|32.86|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|110.83||||110.83|48.88|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|110.83||||110.83|32.86|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|110.83||||110.83|32.86|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|110.83||||110.83|76.47|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|110.83||||110.83|32.86|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|Self-pay|Self-pay|110.83||||110.83|38.79|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|110.83||||110.83|32.86|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|110.83||||110.83|32.86|76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|110.83||||110.83||76.47|32.86
106079|ERX|0250 - PHARMACY-GENERAL|ULIPRISTAL 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|110.83||||110.83||76.47|32.86
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|18.6||||18.6|18.6|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|18.6||||18.6|13.2|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.6||||18.6|5.51|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|18.6||||18.6|8.74|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.6||||18.6|0|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.6||||18.6|9.3|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.6||||18.6|11.72|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.6||||18.6|5.51|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|18.6||||18.6|10.23|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.6||||18.6|12.83|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.6||||18.6|0.15|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.6||||18.6|13.2|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.6||||18.6|5.51|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.6||||18.6|13.2|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.6||||18.6|5.51|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.6||||18.6|5.51|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.6||||18.6|12.83|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.6||||18.6|5.51|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|18.6||||18.6|6.51|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.6||||18.6|5.51|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.6||||18.6|5.51|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.6||||18.6|18.6|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.6||||18.6|18.6|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.6||||18.6||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|13.64||||13.64|11.5|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.64||||13.64||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|13.64||||13.64|6.6|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.64||||13.64|4.04|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.64||||13.64||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.64||||13.64||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|13.64||||13.64|6.41|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.64||||13.64|0|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.64||||13.64|6.82|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.64||||13.64|8.59|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.64||||13.64|4.04|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.64||||13.64||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|13.64||||13.64|7.5|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.64||||13.64|9.41|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.64||||13.64|0.15|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.64||||13.64||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.64||||13.64|6.6|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.64||||13.64|4.04|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.64||||13.64||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.64||||13.64|6.6|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.64||||13.64|4.04|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.64||||13.64|4.04|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.64||||13.64|9.41|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.64||||13.64|4.04|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|Self-pay|Self-pay|13.64||||13.64|4.77|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.64||||13.64|4.04|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.64||||13.64|4.04|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.64||||13.64|11.5|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.64||||13.64||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.64||||13.64||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.64||||13.64|11.5|449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.64||||13.64||449.26|0.15
10608|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 5 MG/ML INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.64||||13.64||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|AARP [1000]|AARP [100000]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|AETNA [1015]|AETNA [101529]|651.1||||651.1|287.14|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|651.1||||651.1|193.05|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|BCBS [1155]|BCBS UTHCT [115568]|651.1||||651.1|306.02|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|651.1||||651.1|325.55|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|651.1||||651.1|325.55|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|651.1||||651.1|410.19|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|651.1||||651.1|193.05|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|CIGNA [1260]|CIGNA GWH [126023]|651.1||||651.1|358.11|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|GROUP PENSION ADMIN [1450]|GPA [145000]|651.1||||651.1|449.26|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|651.1||||651.1|325.55|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|651.1||||651.1|287.14|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|651.1||||651.1|193.05|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|651.1||||651.1|287.14|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|651.1||||651.1|193.05|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|651.1||||651.1|193.05|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|PHCS [1780]|PHCS MULTIPLAN [178000]|651.1||||651.1|449.26|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|651.1||||651.1|193.05|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|Self-pay|Self-pay|651.1||||651.1|227.88|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|651.1||||651.1|193.05|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|651.1||||651.1|193.05|449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|651.1||||651.1||449.26|0.15
10608|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|3.0 NYLON P-12|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|651.1||||651.1||449.26|0.15
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.62||||1.62|0.71|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.62||||1.62|0.48|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.62||||1.62|0.76|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.62||||1.62|0.81|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.62||||1.62|0.81|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.62||||1.62|1.02|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.62||||1.62|0.48|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.62||||1.62|0.89|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.62||||1.62|1.12|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.62||||1.62|0.81|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.62||||1.62|0.71|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.62||||1.62|0.48|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.62||||1.62|0.71|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.62||||1.62|0.48|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.62||||1.62|0.48|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.62||||1.62|1.12|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.62||||1.62|0.48|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.62||||1.62|0.57|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.62||||1.62|0.48|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.62||||1.62|0.48|1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.62||||1.62||1.12|0.48
10609|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.62||||1.62||1.12|0.48
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.28||||2.28|1.01|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.28||||2.28|0.68|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.28||||2.28|1.07|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.28||||2.28|1.14|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.28||||2.28|1.14|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.28||||2.28|1.44|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.28||||2.28|0.68|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.28||||2.28|1.25|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.28||||2.28|1.57|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.28||||2.28|1.14|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.28||||2.28|1.01|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.28||||2.28|0.68|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.28||||2.28|1.01|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.28||||2.28|0.68|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.28||||2.28|0.68|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.28||||2.28|1.57|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.28||||2.28|0.68|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.28||||2.28|0.8|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.28||||2.28|0.68|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.28||||2.28|0.68|1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.28||||2.28||1.57|0.68
10610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIDODRINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.28||||2.28||1.57|0.68
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|502.61||||502.61|446.4|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|502.61||||502.61|149.02|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|502.61||||502.61|236.23|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|502.61||||502.61|0|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|502.61||||502.61|251.31|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|502.61||||502.61|316.64|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|502.61||||502.61|149.02|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|502.61||||502.61|251.31|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|502.61||||502.61|346.8|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|502.61||||502.61|2.5|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|502.61||||502.61|446.4|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|502.61||||502.61|149.02|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|502.61||||502.61|446.4|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|502.61||||502.61|149.02|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|502.61||||502.61|149.02|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|502.61||||502.61|346.8|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|502.61||||502.61|149.02|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|502.61||||502.61|175.91|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|502.61||||502.61|149.02|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|502.61||||502.61|149.02|446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|502.61||||502.61||446.4|2.5
10612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MINOCYCLINE 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|502.61||||502.61||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|AARP [1000]|AARP [100000]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|AETNA [1015]|AETNA [101529]|29.8||||29.8|13.14|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.8||||29.8|8.84|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|BCBS [1155]|BCBS UTHCT [115568]|29.8||||29.8|14.01|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.8||||29.8|14.9|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.8||||29.8|14.9|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.8||||29.8|18.77|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.8||||29.8|8.84|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|CIGNA [1260]|CIGNA GWH [126023]|29.8||||29.8|16.39|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|GROUP PENSION ADMIN [1450]|GPA [145000]|29.8||||29.8|20.56|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29.8||||29.8|14.9|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.8||||29.8|13.14|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.8||||29.8|8.84|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.8||||29.8|13.14|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.8||||29.8|8.84|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|29.8||||29.8|8.84|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|PHCS [1780]|PHCS MULTIPLAN [178000]|29.8||||29.8|20.56|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.8||||29.8|8.84|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|Self-pay|Self-pay|29.8||||29.8|10.43|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29.8||||29.8|8.84|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.8||||29.8|8.84|446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.8||||29.8||446.4|2.5
10612|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|VICRYL 5-0|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.8||||29.8||446.4|2.5
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|AARP [1000]|AARP [100000]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|AETNA [1015]|AETNA [101529]|19.95||||19.95|8.8|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.95||||19.95|5.92|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|BCBS [1155]|BCBS UTHCT [115568]|19.95||||19.95|9.38|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.95||||19.95|9.98|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.95||||19.95|9.98|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.95||||19.95|12.57|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.95||||19.95|5.92|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|CIGNA [1260]|CIGNA GWH [126023]|19.95||||19.95|10.97|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|GROUP PENSION ADMIN [1450]|GPA [145000]|19.95||||19.95|13.77|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.95||||19.95|9.98|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.95||||19.95|8.8|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.95||||19.95|5.92|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.95||||19.95|8.8|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.95||||19.95|5.92|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.95||||19.95|5.92|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|PHCS [1780]|PHCS MULTIPLAN [178000]|19.95||||19.95|13.77|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.95||||19.95|5.92|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|Self-pay|Self-pay|19.95||||19.95|6.98|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.95||||19.95|5.92|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.95||||19.95|5.92|13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.95||||19.95||13.77|5.92
10614|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 6-0|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.95||||19.95||13.77|5.92
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|AARP [1000]|AARP [100000]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|AETNA [1015]|AETNA [101529]|21.62||||21.62|9.54|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.62||||21.62|6.41|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|BCBS [1155]|BCBS UTHCT [115568]|21.62||||21.62|10.16|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.62||||21.62|10.81|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.62||||21.62|10.81|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.62||||21.62|13.62|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.62||||21.62|6.41|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|CIGNA [1260]|CIGNA GWH [126023]|21.62||||21.62|11.89|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|GROUP PENSION ADMIN [1450]|GPA [145000]|21.62||||21.62|14.92|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.62||||21.62|10.81|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.62||||21.62|9.54|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.62||||21.62|6.41|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.62||||21.62|9.54|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.62||||21.62|6.41|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.62||||21.62|6.41|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|PHCS [1780]|PHCS MULTIPLAN [178000]|21.62||||21.62|14.92|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.62||||21.62|6.41|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|Self-pay|Self-pay|21.62||||21.62|7.56|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.62||||21.62|6.41|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.62||||21.62|6.41|14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.62||||21.62||14.92|6.41
10615|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 5-0|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.62||||21.62||14.92|6.41
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AARP [1000]|AARP [100000]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AETNA [1015]|AETNA [101529]|10.2||||10.2|4.5|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.2||||10.2|3.02|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS [1155]|BCBS UTHCT [115568]|10.2||||10.2|4.79|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.2||||10.2|5.1|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.2||||10.2|5.1|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.2||||10.2|6.42|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.2||||10.2|3.02|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|CIGNA [1260]|CIGNA GWH [126023]|10.2||||10.2|5.61|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|GROUP PENSION ADMIN [1450]|GPA [145000]|10.2||||10.2|7.04|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.2||||10.2|5.1|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.2||||10.2|4.5|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.2||||10.2|3.02|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.2||||10.2|4.5|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.2||||10.2|3.02|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.2||||10.2|3.02|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|PHCS [1780]|PHCS MULTIPLAN [178000]|10.2||||10.2|7.04|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.2||||10.2|3.02|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|Self-pay|Self-pay|10.2||||10.2|3.57|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.2||||10.2|3.02|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.2||||10.2|3.02|7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.2||||10.2||7.04|3.02
10616|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.2||||10.2||7.04|3.02
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AARP [1000]|AARP [100000]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AETNA [1015]|AETNA [101529]|24.08||||24.08|10.62|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.08||||24.08|7.14|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS [1155]|BCBS UTHCT [115568]|24.08||||24.08|11.32|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.08||||24.08|12.04|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.08||||24.08|12.04|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.08||||24.08|15.17|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.08||||24.08|7.14|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|CIGNA [1260]|CIGNA GWH [126023]|24.08||||24.08|13.25|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|GROUP PENSION ADMIN [1450]|GPA [145000]|24.08||||24.08|16.62|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.08||||24.08|12.04|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.08||||24.08|10.62|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.08||||24.08|7.14|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.08||||24.08|10.62|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.08||||24.08|7.14|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.08||||24.08|7.14|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|PHCS [1780]|PHCS MULTIPLAN [178000]|24.08||||24.08|16.62|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.08||||24.08|7.14|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|Self-pay|Self-pay|24.08||||24.08|8.43|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.08||||24.08|7.14|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.08||||24.08|7.14|16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.08||||24.08||16.62|7.14
10617|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 4-0|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.08||||24.08||16.62|7.14
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|AARP [1000]|AARP [100000]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|AETNA [1015]|AETNA [101529]|11.43||||11.43|5.04|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.43||||11.43|3.39|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|BCBS [1155]|BCBS UTHCT [115568]|11.43||||11.43|5.37|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.43||||11.43|5.71|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.43||||11.43|5.71|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.43||||11.43|7.2|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.43||||11.43|3.39|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|CIGNA [1260]|CIGNA GWH [126023]|11.43||||11.43|6.28|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11.43||||11.43|7.88|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.43||||11.43|5.71|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.43||||11.43|5.04|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.43||||11.43|3.39|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.43||||11.43|5.04|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.43||||11.43|3.39|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.43||||11.43|3.39|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11.43||||11.43|7.88|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.43||||11.43|3.39|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|Self-pay|Self-pay|11.43||||11.43|4|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.43||||11.43|3.39|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.43||||11.43|3.39|7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.43||||11.43||7.88|3.39
10618|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 3-0|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.43||||11.43||7.88|3.39
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|AARP [1000]|AARP [100000]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|AETNA [1015]|AETNA [101529]|11.25||||11.25|4.96|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.25||||11.25|3.34|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|BCBS [1155]|BCBS UTHCT [115568]|11.25||||11.25|5.29|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.25||||11.25|5.63|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.25||||11.25|5.63|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.25||||11.25|7.09|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.25||||11.25|3.34|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|CIGNA [1260]|CIGNA GWH [126023]|11.25||||11.25|6.19|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11.25||||11.25|7.76|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.25||||11.25|5.63|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.25||||11.25|4.96|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.25||||11.25|3.34|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.25||||11.25|4.96|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.25||||11.25|3.34|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.25||||11.25|3.34|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11.25||||11.25|7.76|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.25||||11.25|3.34|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|Self-pay|Self-pay|11.25||||11.25|3.94|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.25||||11.25|3.34|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.25||||11.25|3.34|7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.25||||11.25||7.76|3.34
10619|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ETHILON SUTURE 2-0|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.25||||11.25||7.76|3.34
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|AARP [1000]|AARP [100000]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|AETNA [1015]|AETNA [101529]|680.63||||680.63|300.16|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|680.63||||680.63|201.81|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|BCBS [1155]|BCBS UTHCT [115568]|680.63||||680.63|319.89|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|680.63||||680.63|340.31|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|680.63||||680.63|340.31|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|680.63||||680.63|428.79|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|680.63||||680.63|201.81|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|CIGNA [1260]|CIGNA GWH [126023]|680.63||||680.63|374.34|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|680.63||||680.63|469.63|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|680.63||||680.63|340.31|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|680.63||||680.63|300.16|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|680.63||||680.63|201.81|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|680.63||||680.63|300.16|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|680.63||||680.63|201.81|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|680.63||||680.63|201.81|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|680.63||||680.63|469.63|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|680.63||||680.63|201.81|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|Self-pay|Self-pay|680.63||||680.63|238.22|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|680.63||||680.63|201.81|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|680.63||||680.63|201.81|469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|680.63||||680.63||469.63|201.81
10621|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|18 FR PEG TUBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|680.63||||680.63||469.63|201.81
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|AARP [1000]|AARP [100000]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|AETNA [1015]|AETNA [101529]|550.55||||550.55|242.79|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|550.55||||550.55|163.24|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|BCBS [1155]|BCBS UTHCT [115568]|550.55||||550.55|258.76|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|550.55||||550.55|275.28|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|550.55||||550.55|275.28|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|550.55||||550.55|346.85|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|550.55||||550.55|163.24|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|CIGNA [1260]|CIGNA GWH [126023]|550.55||||550.55|302.8|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|550.55||||550.55|379.88|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|550.55||||550.55|275.28|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|550.55||||550.55|242.79|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|550.55||||550.55|163.24|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|550.55||||550.55|242.79|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|550.55||||550.55|163.24|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|550.55||||550.55|163.24|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|550.55||||550.55|379.88|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|550.55||||550.55|163.24|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|Self-pay|Self-pay|550.55||||550.55|192.69|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|550.55||||550.55|163.24|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|550.55||||550.55|163.24|379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|550.55||||550.55||379.88|163.24
10622|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|16 FR PEG TUBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|550.55||||550.55||379.88|163.24
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|AARP [1000]|AARP [100000]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|AETNA [1015]|AETNA [101529]|8.88||||8.88|3.92|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.88||||8.88|2.63|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|BCBS [1155]|BCBS UTHCT [115568]|8.88||||8.88|4.17|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.88||||8.88|4.44|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.88||||8.88|4.44|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.88||||8.88|5.59|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.88||||8.88|2.63|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|CIGNA [1260]|CIGNA GWH [126023]|8.88||||8.88|4.88|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8.88||||8.88|6.13|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.88||||8.88|4.44|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.88||||8.88|3.92|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.88||||8.88|2.63|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.88||||8.88|3.92|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.88||||8.88|2.63|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.88||||8.88|2.63|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8.88||||8.88|6.13|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.88||||8.88|2.63|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|Self-pay|Self-pay|8.88||||8.88|3.11|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.88||||8.88|2.63|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.88||||8.88|2.63|6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.88||||8.88||6.13|2.63
10626|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION CATH 6 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.88||||8.88||6.13|2.63
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AARP [1000]|AARP [100000]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|76.31||||76.31|30.43|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76.31||||76.31|22.63|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|76.31||||76.31|35.87|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76.31||||76.31|0|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76.31||||76.31|38.16|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76.31||||76.31|48.08|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76.31||||76.31|22.63|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|76.31||||76.31|41.97|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|76.31||||76.31|52.65|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|76.31||||76.31|8.94|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76.31||||76.31|30.43|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76.31||||76.31|22.63|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76.31||||76.31|30.43|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76.31||||76.31|22.63|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|76.31||||76.31|22.63|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|76.31||||76.31|52.65|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76.31||||76.31|22.63|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|Self-pay|Self-pay|76.31||||76.31|26.71|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|76.31||||76.31|22.63|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76.31||||76.31|22.63|52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76.31||||76.31||52.65|8.94
106278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIAZEPAM 5 MG/ML INJECTION SYRINGE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76.31||||76.31||52.65|8.94
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AARP [1000]|AARP [100000]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AETNA [1015]|AETNA [101529]|0.52||||0.52|0.23|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.52||||0.52|0.15|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.52||||0.52|0.24|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.52||||0.52|0.26|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.52||||0.52|0.26|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.52||||0.52|0.33|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.52||||0.52|0.15|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.52||||0.52|0.29|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.52||||0.52|0.36|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.52||||0.52|0.26|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.52||||0.52|0.23|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.52||||0.52|0.15|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.52||||0.52|0.23|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.52||||0.52|0.15|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.52||||0.52|0.15|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.52||||0.52|0.36|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.52||||0.52|0.15|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|Self-pay|Self-pay|0.52||||0.52|0.18|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.52||||0.52|0.15|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.52||||0.52|0.15|0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.52||||0.52||0.36|0.15
10628|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MISOPROSTOL 100 MCG TABLET|0.25 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.52||||0.52||0.36|0.15
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|AARP [1000]|AARP [100000]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|AETNA [1015]|AETNA [101529]|194.55||||194.55|85.79|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|194.55||||194.55|57.68|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|BCBS [1155]|BCBS UTHCT [115568]|194.55||||194.55|91.44|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|194.55||||194.55|97.27|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|194.55||||194.55|97.27|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|194.55||||194.55|122.56|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|194.55||||194.55|57.68|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|CIGNA [1260]|CIGNA GWH [126023]|194.55||||194.55|107|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|194.55||||194.55|134.24|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|194.55||||194.55|97.27|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|194.55||||194.55|85.79|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|194.55||||194.55|57.68|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|194.55||||194.55|85.79|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|194.55||||194.55|57.68|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|194.55||||194.55|57.68|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|194.55||||194.55|134.24|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|194.55||||194.55|57.68|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|Self-pay|Self-pay|194.55||||194.55|68.1|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|194.55||||194.55|57.68|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|194.55||||194.55|57.68|134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|194.55||||194.55||134.24|57.68
10629|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MM-FLOW LENS,EYE IRRIGATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|194.55||||194.55||134.24|57.68
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|AARP [1000]|AARP [100000]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|AETNA [1015]|AETNA [101529]|1959.14||||1959.14|549.22|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1959.14||||1959.14|580.89|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS [1155]|BCBS UTHCT [115568]|1959.14||||1959.14|920.8|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1959.14||||1959.14|0|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1959.14||||1959.14|979.57|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1959.14||||1959.14|1234.26|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1959.14||||1959.14|580.89|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|CIGNA [1260]|CIGNA GWH [126023]|1959.14||||1959.14|979.57|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1959.14||||1959.14|1351.81|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1959.14||||1959.14|67.8|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1959.14||||1959.14|549.22|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1959.14||||1959.14|580.89|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1959.14||||1959.14|549.22|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1959.14||||1959.14|580.89|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|1959.14||||1959.14|580.89|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1959.14||||1959.14|1351.81|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1959.14||||1959.14|580.89|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|Self-pay|Self-pay|1959.14||||1959.14|685.7|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1959.14||||1959.14|580.89|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1959.14||||1959.14|580.89|1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1959.14||||1959.14||1351.81|67.8
10630|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOMYCIN 20 MG INTRAVENOUS SOLUTION|20 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1959.14||||1959.14||1351.81|67.8
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|AARP [1000]|AARP [100000]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|AETNA [1015]|AETNA [101529]|117.29||||117.29|51.72|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|117.29||||117.29|34.78|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|BCBS [1155]|BCBS UTHCT [115568]|117.29||||117.29|55.12|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|117.29||||117.29|58.64|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|117.29||||117.29|58.64|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|117.29||||117.29|73.89|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|117.29||||117.29|34.78|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|CIGNA [1260]|CIGNA GWH [126023]|117.29||||117.29|64.51|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|GROUP PENSION ADMIN [1450]|GPA [145000]|117.29||||117.29|80.93|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|117.29||||117.29|58.64|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|117.29||||117.29|51.72|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|117.29||||117.29|34.78|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|117.29||||117.29|51.72|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|117.29||||117.29|34.78|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|117.29||||117.29|34.78|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|PHCS [1780]|PHCS MULTIPLAN [178000]|117.29||||117.29|80.93|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|117.29||||117.29|34.78|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|Self-pay|Self-pay|117.29||||117.29|41.05|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|117.29||||117.29|34.78|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|117.29||||117.29|34.78|80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|117.29||||117.29||80.93|34.78
10632|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GLIDESCOPE SLEEVE SIZE 4 10/BOX. #0270-0628.|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|117.29||||117.29||80.93|34.78
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AARP [1000]|AARP [100000]|1.55||||1.55|1.55|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.55||||1.55||1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AETNA [1015]|AETNA [101529]|1.55||||1.55|0.96|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.55||||1.55|0.46|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.55||||1.55||1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.55||||1.55||1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BCBS UTHCT [115568]|1.55||||1.55|0.73|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.55||||1.55|0|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.55||||1.55|0.78|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.55||||1.55|0.98|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.55||||1.55|0.46|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.55||||1.55||1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|CIGNA [1260]|CIGNA GWH [126023]|1.55||||1.55|0.85|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.55||||1.55|1.07|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.55||||1.55|0.11|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.55||||1.55||1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.55||||1.55|0.96|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.55||||1.55|0.46|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.55||||1.55||1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.55||||1.55|0.96|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.55||||1.55|0.46|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.55||||1.55|0.46|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.55||||1.55|1.07|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.55||||1.55|0.46|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|Self-pay|Self-pay|1.55||||1.55|0.54|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.55||||1.55|0.46|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.55||||1.55|0.46|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.55||||1.55|1.55|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.55||||1.55||1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.55||||1.55||1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.55||||1.55|1.55|1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.55||||1.55||1.55|0.11
106348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON HCL (PF) 4 MG/2 ML INJECTION SOLUTION *2 ML VIAL*|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.55||||1.55||1.55|0.11
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|AARP [1000]|AARP [100000]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|AETNA [1015]|AETNA [101529]|214.08||||214.08|94.41|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214.08||||214.08|63.47|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|BCBS [1155]|BCBS UTHCT [115568]|214.08||||214.08|100.62|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214.08||||214.08|107.04|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214.08||||214.08|107.04|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214.08||||214.08|134.87|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214.08||||214.08|63.47|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|CIGNA [1260]|CIGNA GWH [126023]|214.08||||214.08|117.74|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214.08||||214.08|147.72|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214.08||||214.08|107.04|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214.08||||214.08|94.41|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214.08||||214.08|63.47|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214.08||||214.08|94.41|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214.08||||214.08|63.47|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214.08||||214.08|63.47|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214.08||||214.08|147.72|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214.08||||214.08|63.47|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|Self-pay|Self-pay|214.08||||214.08|74.93|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214.08||||214.08|63.47|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214.08||||214.08|63.47|147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214.08||||214.08||147.72|63.47
10636|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATION SYRINGE 60 CC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214.08||||214.08||147.72|63.47
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|AARP [1000]|AARP [100000]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|39.06||||39.06|17.23|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.06||||39.06|11.58|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|39.06||||39.06|18.36|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.06||||39.06|19.53|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.06||||39.06|19.53|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.06||||39.06|24.61|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.06||||39.06|11.58|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|39.06||||39.06|21.48|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.06||||39.06|26.95|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|39.06||||39.06|19.53|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.06||||39.06|17.23|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.06||||39.06|11.58|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.06||||39.06|17.23|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.06||||39.06|11.58|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|39.06||||39.06|11.58|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.06||||39.06|26.95|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.06||||39.06|11.58|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|Self-pay|Self-pay|39.06||||39.06|13.67|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|39.06||||39.06|11.58|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.06||||39.06|11.58|26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.06||||39.06||26.95|11.58
106363|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.06||||39.06||26.95|11.58
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|AARP [1000]|AARP [100000]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|AETNA [1015]|AETNA [101529]|7757.5||||7757.5|3421.06|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7757.5||||7757.5|2300.1|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|BCBS [1155]|BCBS UTHCT [115568]|7757.5||||7757.5|3646.03|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7757.5||||7757.5|3878.75|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7757.5||||7757.5|3878.75|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7757.5||||7757.5|4887.23|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7757.5||||7757.5|2300.1|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|CIGNA [1260]|CIGNA GWH [126023]|7757.5||||7757.5|4266.63|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7757.5||||7757.5|5352.68|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7757.5||||7757.5|3878.75|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7757.5||||7757.5|3421.06|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7757.5||||7757.5|2300.1|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7757.5||||7757.5|3421.06|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7757.5||||7757.5|2300.1|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|7757.5||||7757.5|2300.1|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7757.5||||7757.5|5352.68|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7757.5||||7757.5|2300.1|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|Self-pay|Self-pay|7757.5||||7757.5|2715.12|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7757.5||||7757.5|2300.1|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7757.5||||7757.5|2300.1|5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7757.5||||7757.5||5352.68|2300.1
10637|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO PH CAPSULE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7757.5||||7757.5||5352.68|2300.1
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|AARP [1000]|AARP [100000]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|AETNA [1015]|AETNA [101529]|1583.6||||1583.6|698.37|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1583.6||||1583.6|469.54|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|BCBS [1155]|BCBS UTHCT [115568]|1583.6||||1583.6|744.29|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1583.6||||1583.6|791.8|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1583.6||||1583.6|791.8|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1583.6||||1583.6|997.67|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1583.6||||1583.6|469.54|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|CIGNA [1260]|CIGNA GWH [126023]|1583.6||||1583.6|870.98|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1583.6||||1583.6|1092.68|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1583.6||||1583.6|791.8|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1583.6||||1583.6|698.37|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1583.6||||1583.6|469.54|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1583.6||||1583.6|698.37|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1583.6||||1583.6|469.54|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1583.6||||1583.6|469.54|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1583.6||||1583.6|1092.68|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1583.6||||1583.6|469.54|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|Self-pay|Self-pay|1583.6||||1583.6|554.26|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1583.6||||1583.6|469.54|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1583.6||||1583.6|469.54|1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1583.6||||1583.6||1092.68|469.54
10639|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMIN-35 PRELOA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1583.6||||1583.6||1092.68|469.54
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|AARP [1000]|AARP [100000]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|AETNA [1015]|AETNA [101529]|1198.4||||1198.4|528.49|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1198.4||||1198.4|355.33|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|BCBS [1155]|BCBS UTHCT [115568]|1198.4||||1198.4|563.25|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1198.4||||1198.4|599.2|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1198.4||||1198.4|599.2|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1198.4||||1198.4|754.99|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1198.4||||1198.4|355.33|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|CIGNA [1260]|CIGNA GWH [126023]|1198.4||||1198.4|659.12|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1198.4||||1198.4|826.9|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1198.4||||1198.4|599.2|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1198.4||||1198.4|528.49|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1198.4||||1198.4|355.33|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1198.4||||1198.4|528.49|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1198.4||||1198.4|355.33|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1198.4||||1198.4|355.33|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1198.4||||1198.4|826.9|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1198.4||||1198.4|355.33|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|Self-pay|Self-pay|1198.4||||1198.4|419.44|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1198.4||||1198.4|355.33|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1198.4||||1198.4|355.33|826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1198.4||||1198.4||826.9|355.33
10640|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPHINTERTOME FS-OMNI-21480 PRE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1198.4||||1198.4||826.9|355.33
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AARP [1000]|AARP [100000]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AARP [1000]|AARP [100000]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AETNA [1015]|AETNA [101529]|9.05||||9.05|3.99|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AETNA [1015]|AETNA [101529]|9.05||||9.05|3.99|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|9.05||||9.05|4.25|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|9.05||||9.05|4.25|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.05||||9.05|4.53|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.05||||9.05|4.53|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.05||||9.05|4.53|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.05||||9.05|4.53|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.05||||9.05|5.7|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.05||||9.05|5.7|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|9.05||||9.05|4.98|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|9.05||||9.05|4.98|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.05||||9.05|6.24|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.05||||9.05|6.24|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.05||||9.05|4.53|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.05||||9.05|4.53|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.05||||9.05|3.99|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.05||||9.05|3.99|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.05||||9.05|3.99|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.05||||9.05|3.99|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.05||||9.05|6.24|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.05||||9.05|6.24|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|Self-pay|Self-pay|9.05||||9.05|3.17|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|Self-pay|Self-pay|9.05||||9.05|3.17|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.05||||9.05|2.68|6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.05||||9.05||6.24|2.68
106413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-CHLORPHENIRAMINE 8 MG/5 ML ORAL SUSP EXTEND.REL 12HR REPACK|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.05||||9.05||6.24|2.68
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|AARP [1000]|AARP [100000]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|AETNA [1015]|AETNA [101529]|2573.35||||2573.35|1134.85|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2573.35||||2573.35|763|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|BCBS [1155]|BCBS UTHCT [115568]|2573.35||||2573.35|1209.47|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2573.35||||2573.35|1286.68|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2573.35||||2573.35|1286.68|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2573.35||||2573.35|1621.21|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2573.35||||2573.35|763|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|CIGNA [1260]|CIGNA GWH [126023]|2573.35||||2573.35|1415.34|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2573.35||||2573.35|1775.61|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2573.35||||2573.35|1286.68|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2573.35||||2573.35|1134.85|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2573.35||||2573.35|763|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2573.35||||2573.35|1134.85|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2573.35||||2573.35|763|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2573.35||||2573.35|763|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2573.35||||2573.35|1775.61|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2573.35||||2573.35|763|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|Self-pay|Self-pay|2573.35||||2573.35|900.67|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2573.35||||2573.35|763|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2573.35||||2573.35|763|1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2573.35||||2573.35||1775.61|763
10642|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DEVICE, CAPSULE DELIV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2573.35||||2573.35||1775.61|763
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|AARP [1000]|AARP [100000]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|AETNA [1015]|AETNA [101529]|13910||||13910|6134.31|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13910||||13910|4124.32|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|BCBS [1155]|BCBS UTHCT [115568]|13910||||13910|6537.7|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13910||||13910|6955|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13910||||13910|6955|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13910||||13910|8763.3|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13910||||13910|4124.32|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|CIGNA [1260]|CIGNA GWH [126023]|13910||||13910|7650.5|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13910||||13910|9597.9|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13910||||13910|6955|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13910||||13910|6134.31|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13910||||13910|4124.32|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13910||||13910|6134.31|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13910||||13910|4124.32|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|13910||||13910|4124.32|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13910||||13910|9597.9|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13910||||13910|4124.32|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|Self-pay|Self-pay|13910||||13910|4868.5|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13910||||13910|4124.32|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13910||||13910|4124.32|9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13910||||13910||9597.9|4124.32
10643|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, ABLATION HALO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13910||||13910||9597.9|4124.32
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|AARP [1000]|AARP [100000]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|AETNA [1015]|AETNA [101529]|200.7||||200.7|88.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|200.7||||200.7|59.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|BCBS [1155]|BCBS UTHCT [115568]|200.7||||200.7|94.33|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|200.7||||200.7|100.35|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|200.7||||200.7|100.35|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|200.7||||200.7|126.44|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|200.7||||200.7|59.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|CIGNA [1260]|CIGNA GWH [126023]|200.7||||200.7|110.39|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|200.7||||200.7|138.48|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|200.7||||200.7|100.35|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|200.7||||200.7|88.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|200.7||||200.7|59.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|200.7||||200.7|88.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|200.7||||200.7|59.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|200.7||||200.7|59.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|200.7||||200.7|138.48|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|200.7||||200.7|59.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|Self-pay|Self-pay|200.7||||200.7|70.24|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|200.7||||200.7|59.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|200.7||||200.7|59.51|138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|200.7||||200.7||138.48|59.51
10644|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, CAP HALO MEDIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|200.7||||200.7||138.48|59.51
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|AARP [1000]|AARP [100000]|847||||847|381.15|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|847||||847||584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|AETNA [1015]|AETNA [101529]|847||||847|373.53|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|847||||847|251.14|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|847||||847||584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|847||||847||584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|BCBS [1155]|BCBS UTHCT [115568]|847||||847|398.09|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|847||||847|423.5|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|847||||847|423.5|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|847||||847|533.61|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|847||||847|251.14|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|847||||847||584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|CIGNA [1260]|CIGNA GWH [126023]|847||||847|465.85|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|847||||847|584.43|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|847||||847|423.5|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|847||||847||584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|847||||847|373.53|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|847||||847|251.14|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|847||||847||584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|847||||847|373.53|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|847||||847|251.14|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|847||||847|251.14|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|847||||847|584.43|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|847||||847|251.14|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|Self-pay|Self-pay|847||||847|296.45|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|847||||847|251.14|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|847||||847|251.14|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|847||||847|381.15|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|847||||847||584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|847||||847||584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|847||||847|381.15|584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|847||||847||584.43|251.14
10645|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE HALO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|847||||847||584.43|251.14
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|AARP [1000]|AARP [100000]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|AETNA [1015]|AETNA [101529]|726||||726|320.17|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|726||||726|215.26|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|BCBS [1155]|BCBS UTHCT [115568]|726||||726|341.22|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|726||||726|363|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|726||||726|363|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|726||||726|457.38|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|726||||726|215.26|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|CIGNA [1260]|CIGNA GWH [126023]|726||||726|399.3|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|726||||726|500.94|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|726||||726|363|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|726||||726|320.17|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|726||||726|215.26|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|726||||726|320.17|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|726||||726|215.26|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|726||||726|215.26|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|726||||726|500.94|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|726||||726|215.26|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|Self-pay|Self-pay|726||||726|254.1|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|726||||726|215.26|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|726||||726|215.26|500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|726||||726||500.94|215.26
10647|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG KIT 20FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|726||||726||500.94|215.26
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|AARP [1000]|AARP [100000]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|AETNA [1015]|AETNA [101529]|1546.15||||1546.15|681.85|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1546.15||||1546.15|458.43|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|BCBS [1155]|BCBS UTHCT [115568]|1546.15||||1546.15|726.69|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1546.15||||1546.15|773.08|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1546.15||||1546.15|773.08|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1546.15||||1546.15|974.07|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1546.15||||1546.15|458.43|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|CIGNA [1260]|CIGNA GWH [126023]|1546.15||||1546.15|850.38|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1546.15||||1546.15|1066.84|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1546.15||||1546.15|773.08|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1546.15||||1546.15|681.85|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1546.15||||1546.15|458.43|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1546.15||||1546.15|681.85|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1546.15||||1546.15|458.43|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1546.15||||1546.15|458.43|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1546.15||||1546.15|1066.84|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1546.15||||1546.15|458.43|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|Self-pay|Self-pay|1546.15||||1546.15|541.15|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1546.15||||1546.15|458.43|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1546.15||||1546.15|458.43|1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1546.15||||1546.15||1066.84|458.43
10649|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DILATORS, WIRE BALLOON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1546.15||||1546.15||1066.84|458.43
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|24.65||||24.65|10.87|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.65||||24.65|7.31|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|24.65||||24.65|11.59|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.65||||24.65|12.33|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.65||||24.65|12.33|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.65||||24.65|15.53|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.65||||24.65|7.31|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|24.65||||24.65|13.56|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|24.65||||24.65|17.01|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.65||||24.65|12.33|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.65||||24.65|10.87|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.65||||24.65|7.31|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.65||||24.65|10.87|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.65||||24.65|7.31|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.65||||24.65|7.31|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|24.65||||24.65|17.01|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.65||||24.65|7.31|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|Self-pay|Self-pay|24.65||||24.65|8.63|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.65||||24.65|7.31|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.65||||24.65|7.31|17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.65||||24.65||17.01|7.31
106491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DABIGATRAN ETEXILATE 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.65||||24.65||17.01|7.31
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|AARP [1000]|AARP [100000]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|AETNA [1015]|AETNA [101529]|496.1||||496.1|218.78|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|496.1||||496.1|147.09|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|BCBS [1155]|BCBS UTHCT [115568]|496.1||||496.1|233.17|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|496.1||||496.1|248.05|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|496.1||||496.1|248.05|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|496.1||||496.1|312.54|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|496.1||||496.1|147.09|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|CIGNA [1260]|CIGNA GWH [126023]|496.1||||496.1|272.86|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|496.1||||496.1|342.31|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|496.1||||496.1|248.05|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|496.1||||496.1|218.78|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|496.1||||496.1|147.09|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|496.1||||496.1|218.78|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|496.1||||496.1|147.09|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|496.1||||496.1|147.09|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|496.1||||496.1|342.31|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|496.1||||496.1|147.09|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|Self-pay|Self-pay|496.1||||496.1|173.63|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|496.1||||496.1|147.09|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|496.1||||496.1|147.09|342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|496.1||||496.1||342.31|147.09
10650|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEG TRAY, FLOW 20 PULL METHOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|496.1||||496.1||342.31|147.09
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|AARP [1000]|AARP [100000]|779.85||||779.85|350.93|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|779.85||||779.85||538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|AETNA [1015]|AETNA [101529]|779.85||||779.85|343.91|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|779.85||||779.85|231.22|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|779.85||||779.85||538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|779.85||||779.85||538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|BCBS [1155]|BCBS UTHCT [115568]|779.85||||779.85|366.53|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|779.85||||779.85|389.92|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|779.85||||779.85|389.92|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|779.85||||779.85|491.3|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|779.85||||779.85|231.22|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|779.85||||779.85||538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|CIGNA [1260]|CIGNA GWH [126023]|779.85||||779.85|428.91|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|GROUP PENSION ADMIN [1450]|GPA [145000]|779.85||||779.85|538.09|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|779.85||||779.85|389.92|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|779.85||||779.85||538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|779.85||||779.85|343.91|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|779.85||||779.85|231.22|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|779.85||||779.85||538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|779.85||||779.85|343.91|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|779.85||||779.85|231.22|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|779.85||||779.85|231.22|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|PHCS [1780]|PHCS MULTIPLAN [178000]|779.85||||779.85|538.09|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|779.85||||779.85|231.22|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|Self-pay|Self-pay|779.85||||779.85|272.95|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|779.85||||779.85|231.22|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|779.85||||779.85|231.22|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|779.85||||779.85|350.93|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|779.85||||779.85||538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|779.85||||779.85||538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|779.85||||779.85|350.93|538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|779.85||||779.85||538.09|231.22
10652|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GUIDEWIRE, MET11|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|779.85||||779.85||538.09|231.22
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|AARP [1000]|AARP [100000]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|AETNA [1015]|AETNA [101529]|277.64||||277.64|122.44|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.64||||277.64|82.32|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|BCBS [1155]|BCBS UTHCT [115568]|277.64||||277.64|130.49|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.64||||277.64|138.82|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.64||||277.64|138.82|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.64||||277.64|174.91|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.64||||277.64|82.32|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|CIGNA [1260]|CIGNA GWH [126023]|277.64||||277.64|152.7|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277.64||||277.64|191.57|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|277.64||||277.64|130.49|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.64||||277.64|122.44|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.64||||277.64|82.32|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.64||||277.64|122.44|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.64||||277.64|82.32|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|277.64||||277.64|82.32|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277.64||||277.64|191.57|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.64||||277.64|82.32|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|Self-pay|Self-pay|277.64||||277.64|97.18|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|277.64||||277.64|82.32|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.64||||277.64|82.32|191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.64||||277.64||191.57|82.32
10653|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BALLOON REPLACEMENT TUBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277.64||||277.64||191.57|82.32
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|AARP [1000]|AARP [100000]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|AETNA [1015]|AETNA [101529]|871.6||||871.6|384.38|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|871.6||||871.6|258.43|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|BCBS [1155]|BCBS UTHCT [115568]|871.6||||871.6|409.65|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|871.6||||871.6|435.8|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|871.6||||871.6|435.8|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|871.6||||871.6|549.11|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|871.6||||871.6|258.43|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|CIGNA [1260]|CIGNA GWH [126023]|871.6||||871.6|479.38|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|871.6||||871.6|601.4|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|871.6||||871.6|435.8|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|871.6||||871.6|384.38|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|871.6||||871.6|258.43|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|871.6||||871.6|384.38|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|871.6||||871.6|258.43|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|871.6||||871.6|258.43|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|871.6||||871.6|601.4|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|871.6||||871.6|258.43|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|Self-pay|Self-pay|871.6||||871.6|305.06|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|871.6||||871.6|258.43|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|871.6||||871.6|258.43|601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|871.6||||871.6||601.4|258.43
10654|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CLIP INSTINCT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|871.6||||871.6||601.4|258.43
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AARP [1000]|AARP [100000]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AARP [1000]|AARP [100000]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AETNA [1015]|AETNA [101529]|1.71||||1.71|0.75|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AETNA [1015]|AETNA [101529]|1.71||||1.71|0.75|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|1.71||||1.71|0.8|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|1.71||||1.71|0.8|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.71||||1.71|0.86|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.71||||1.71|0.86|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.71||||1.71|0.86|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.71||||1.71|0.86|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.71||||1.71|1.08|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.71||||1.71|1.08|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|1.71||||1.71|0.94|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|1.71||||1.71|0.94|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.71||||1.71|1.18|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.71||||1.71|1.18|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.71||||1.71|0.86|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.71||||1.71|0.86|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.71||||1.71|0.75|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.71||||1.71|0.75|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.71||||1.71|0.75|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.71||||1.71|0.75|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.71||||1.71|1.18|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.71||||1.71|1.18|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|Self-pay|Self-pay|1.71||||1.71|0.6|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|Self-pay|Self-pay|1.71||||1.71|0.6|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|AARP [1000]|AARP [100000]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|AETNA [1015]|AETNA [101529]|1.71||||1.71|0.75|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|BCBS [1155]|BCBS UTHCT [115568]|1.71||||1.71|0.8|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.71||||1.71|0.86|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.71||||1.71|0.86|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.71||||1.71|1.08|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|CIGNA [1260]|CIGNA GWH [126023]|1.71||||1.71|0.94|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.71||||1.71|1.18|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.71||||1.71|0.86|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.71||||1.71|0.75|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.71||||1.71|0.75|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.71||||1.71|1.18|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|Self-pay|Self-pay|1.71||||1.71|0.6|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.71||||1.71|0.51|1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.71||||1.71||1.18|0.51
10655|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE CONCENTRATE 100 MG/5 ML (20 MG/ML) ORAL SOLUTION REPACK|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.71||||1.71||1.18|0.51
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|AARP [1000]|AARP [100000]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|AETNA [1015]|AETNA [101529]|635.25||||635.25|280.15|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|635.25||||635.25|188.35|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|BCBS [1155]|BCBS UTHCT [115568]|635.25||||635.25|298.57|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|635.25||||635.25|317.63|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|635.25||||635.25|317.63|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|635.25||||635.25|400.21|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|635.25||||635.25|188.35|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|CIGNA [1260]|CIGNA GWH [126023]|635.25||||635.25|349.39|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|GROUP PENSION ADMIN [1450]|GPA [145000]|635.25||||635.25|438.32|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|635.25||||635.25|317.63|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|635.25||||635.25|280.15|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|635.25||||635.25|188.35|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|635.25||||635.25|280.15|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|635.25||||635.25|188.35|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|635.25||||635.25|188.35|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|PHCS [1780]|PHCS MULTIPLAN [178000]|635.25||||635.25|438.32|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|635.25||||635.25|188.35|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|Self-pay|Self-pay|635.25||||635.25|222.34|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|635.25||||635.25|188.35|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|635.25||||635.25|188.35|438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|635.25||||635.25||438.32|188.35
10657|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CYTOLOGY BRUSH 1.5 S|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|635.25||||635.25||438.32|188.35
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|AARP [1000]|AARP [100000]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|AETNA [1015]|AETNA [101529]|871.6||||871.6|384.38|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|871.6||||871.6|258.43|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|BCBS [1155]|BCBS UTHCT [115568]|871.6||||871.6|409.65|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|871.6||||871.6|435.8|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|871.6||||871.6|435.8|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|871.6||||871.6|549.11|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|871.6||||871.6|258.43|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|CIGNA [1260]|CIGNA GWH [126023]|871.6||||871.6|479.38|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|871.6||||871.6|601.4|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|871.6||||871.6|435.8|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|871.6||||871.6|384.38|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|871.6||||871.6|258.43|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|871.6||||871.6|384.38|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|871.6||||871.6|258.43|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|871.6||||871.6|258.43|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|871.6||||871.6|601.4|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|871.6||||871.6|258.43|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|Self-pay|Self-pay|871.6||||871.6|305.06|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|871.6||||871.6|258.43|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|871.6||||871.6|258.43|601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|871.6||||871.6||601.4|258.43
10658|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUICK SILVER PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|871.6||||871.6||601.4|258.43
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|AARP [1000]|AARP [100000]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|AETNA [1015]|AETNA [101529]|12034.83||||12034.83|5307.36|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12034.83||||12034.83|3568.33|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|BCBS [1155]|BCBS UTHCT [115568]|12034.83||||12034.83|5656.37|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12034.83||||12034.83|6017.41|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12034.83||||12034.83|6017.41|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12034.83||||12034.83|7581.94|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12034.83||||12034.83|3568.33|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|CIGNA [1260]|CIGNA GWH [126023]|12034.83||||12034.83|6619.15|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12034.83||||12034.83|8304.03|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12034.83||||12034.83|6017.41|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12034.83||||12034.83|5307.36|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12034.83||||12034.83|3568.33|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12034.83||||12034.83|5307.36|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12034.83||||12034.83|3568.33|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|12034.83||||12034.83|3568.33|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12034.83||||12034.83|8304.03|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12034.83||||12034.83|3568.33|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|Self-pay|Self-pay|12034.83||||12034.83|4212.19|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12034.83||||12034.83|3568.33|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12034.83||||12034.83|3568.33|8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12034.83||||12034.83||8304.03|3568.33
10659|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE CIRCUMFLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12034.83||||12034.83||8304.03|3568.33
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|AARP [1000]|AARP [100000]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|AETNA [1015]|AETNA [101529]|8672.35||||8672.35|3824.51|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|BCBS [1155]|BCBS UTHCT [115568]|8672.35||||8672.35|4076|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8672.35||||8672.35|4336.18|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8672.35||||8672.35|4336.18|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8672.35||||8672.35|5463.58|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|CIGNA [1260]|CIGNA GWH [126023]|8672.35||||8672.35|4769.79|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8672.35||||8672.35|5983.92|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8672.35||||8672.35|4336.18|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8672.35||||8672.35|3824.51|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8672.35||||8672.35|3824.51|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8672.35||||8672.35|2571.35|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8672.35||||8672.35|5983.92|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8672.35||||8672.35|2571.35|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|Self-pay|Self-pay|8672.35||||8672.35|3035.32|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8672.35||||8672.35|2571.35|5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8672.35||||8672.35||5983.92|2571.35
10660|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, BARRX CHN RFA ENDOSCOPIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8672.35||||8672.35||5983.92|2571.35
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|AARP [1000]|AARP [100000]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|AETNA [1015]|AETNA [101529]|22.33||||22.33|9.85|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.33||||22.33|6.62|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|BCBS [1155]|BCBS UTHCT [115568]|22.33||||22.33|10.49|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.33||||22.33|11.16|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.33||||22.33|11.16|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.33||||22.33|14.07|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.33||||22.33|6.62|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|CIGNA [1260]|CIGNA GWH [126023]|22.33||||22.33|12.28|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|22.33||||22.33|15.41|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22.33||||22.33|11.16|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.33||||22.33|9.85|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.33||||22.33|6.62|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.33||||22.33|9.85|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.33||||22.33|6.62|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|22.33||||22.33|6.62|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|22.33||||22.33|15.41|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.33||||22.33|6.62|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|Self-pay|Self-pay|22.33||||22.33|7.82|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22.33||||22.33|6.62|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.33||||22.33|6.62|15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.33||||22.33||15.41|6.62
10663|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|4/0 ETHICON SUTURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.33||||22.33||15.41|6.62
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|AARP [1000]|AARP [100000]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|AETNA [1015]|AETNA [101529]|33.4||||33.4|14.73|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.4||||33.4|9.9|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|BCBS [1155]|BCBS UTHCT [115568]|33.4||||33.4|15.7|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.4||||33.4|16.7|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.4||||33.4|16.7|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.4||||33.4|21.04|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.4||||33.4|9.9|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|CIGNA [1260]|CIGNA GWH [126023]|33.4||||33.4|18.37|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|33.4||||33.4|23.05|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.4||||33.4|16.7|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.4||||33.4|14.73|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.4||||33.4|9.9|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.4||||33.4|14.73|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.4||||33.4|9.9|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.4||||33.4|9.9|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|33.4||||33.4|23.05|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.4||||33.4|9.9|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|Self-pay|Self-pay|33.4||||33.4|11.69|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.4||||33.4|9.9|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.4||||33.4|9.9|23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.4||||33.4||23.05|9.9
10665|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|5/0 PROLENE SUTURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.4||||33.4||23.05|9.9
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|AARP [1000]|AARP [100000]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|AETNA [1015]|AETNA [101529]|6.15||||6.15|2.71|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.15||||6.15|1.82|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|BCBS [1155]|BCBS UTHCT [115568]|6.15||||6.15|2.89|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.15||||6.15|3.08|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.15||||6.15|3.08|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.15||||6.15|3.88|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.15||||6.15|1.82|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|CIGNA [1260]|CIGNA GWH [126023]|6.15||||6.15|3.38|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6.15||||6.15|4.25|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.15||||6.15|3.08|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.15||||6.15|2.71|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.15||||6.15|1.82|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.15||||6.15|2.71|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.15||||6.15|1.82|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.15||||6.15|1.82|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6.15||||6.15|4.25|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.15||||6.15|1.82|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|Self-pay|Self-pay|6.15||||6.15|2.15|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.15||||6.15|1.82|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.15||||6.15|1.82|4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.15||||6.15||4.25|1.82
10667|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|"6"" PADDED FINGER SPLINT"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.15||||6.15||4.25|1.82
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|AARP [1000]|AARP [100000]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|AETNA [1015]|AETNA [101529]|7.21||||7.21|3.18|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.21||||7.21|2.14|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|BCBS [1155]|BCBS UTHCT [115568]|7.21||||7.21|3.39|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.21||||7.21|3.6|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.21||||7.21|3.6|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.21||||7.21|4.54|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.21||||7.21|2.14|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|CIGNA [1260]|CIGNA GWH [126023]|7.21||||7.21|3.96|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7.21||||7.21|4.97|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.21||||7.21|3.6|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.21||||7.21|3.18|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.21||||7.21|2.14|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.21||||7.21|3.18|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.21||||7.21|2.14|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.21||||7.21|2.14|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7.21||||7.21|4.97|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.21||||7.21|2.14|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|Self-pay|Self-pay|7.21||||7.21|2.52|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.21||||7.21|2.14|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.21||||7.21|2.14|4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.21||||7.21||4.97|2.14
10668|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|LARGE PADDED FINGER SPLINT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.21||||7.21||4.97|2.14
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|AARP [1000]|AARP [100000]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|AETNA [1015]|AETNA [101529]|82.36||||82.36|36.32|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82.36||||82.36|24.42|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|BCBS [1155]|BCBS UTHCT [115568]|82.36||||82.36|38.71|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|82.36||||82.36|41.18|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|82.36||||82.36|41.18|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|82.36||||82.36|51.89|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|82.36||||82.36|24.42|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|CIGNA [1260]|CIGNA GWH [126023]|82.36||||82.36|45.3|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|82.36||||82.36|56.83|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|82.36||||82.36|41.18|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82.36||||82.36|36.32|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82.36||||82.36|24.42|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82.36||||82.36|36.32|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82.36||||82.36|24.42|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|82.36||||82.36|24.42|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|82.36||||82.36|56.83|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82.36||||82.36|24.42|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|Self-pay|Self-pay|82.36||||82.36|28.82|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|82.36||||82.36|24.42|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|82.36||||82.36|24.42|56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82.36||||82.36||56.83|24.42
10669|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAUTERY HIGH TEMP FINE TIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|82.36||||82.36||56.83|24.42
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|AARP [1000]|AARP [100000]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|AETNA [1015]|AETNA [101529]|140.25||||140.25|61.85|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|140.25||||140.25|41.58|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|BCBS [1155]|BCBS UTHCT [115568]|140.25||||140.25|65.92|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|140.25||||140.25|70.13|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|140.25||||140.25|70.13|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|140.25||||140.25|88.36|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|140.25||||140.25|41.58|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|CIGNA [1260]|CIGNA GWH [126023]|140.25||||140.25|77.14|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|140.25||||140.25|96.77|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|140.25||||140.25|70.13|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|140.25||||140.25|61.85|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|140.25||||140.25|41.58|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|140.25||||140.25|61.85|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|140.25||||140.25|41.58|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|140.25||||140.25|41.58|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|140.25||||140.25|96.77|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|140.25||||140.25|41.58|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|Self-pay|Self-pay|140.25||||140.25|49.09|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|140.25||||140.25|41.58|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|140.25||||140.25|41.58|96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|140.25||||140.25||96.77|41.58
10670|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP RAD JAW JUMBO 2.8 W.NDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|140.25||||140.25||96.77|41.58
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|AARP [1000]|AARP [100000]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|AETNA [1015]|AETNA [101529]|200.7||||200.7|88.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|200.7||||200.7|59.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|BCBS [1155]|BCBS UTHCT [115568]|200.7||||200.7|94.33|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|200.7||||200.7|100.35|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|200.7||||200.7|100.35|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|200.7||||200.7|126.44|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|200.7||||200.7|59.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|CIGNA [1260]|CIGNA GWH [126023]|200.7||||200.7|110.39|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|200.7||||200.7|138.48|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|200.7||||200.7|100.35|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|200.7||||200.7|88.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|200.7||||200.7|59.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|200.7||||200.7|88.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|200.7||||200.7|59.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|200.7||||200.7|59.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|200.7||||200.7|138.48|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|200.7||||200.7|59.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|Self-pay|Self-pay|200.7||||200.7|70.24|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|200.7||||200.7|59.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|200.7||||200.7|59.51|138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|200.7||||200.7||138.48|59.51
10671|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FORCEP BX CAPTURA MINI W/O SPK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|200.7||||200.7||138.48|59.51
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AARP [1000]|AARP [100000]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AETNA [1015]|AETNA [101529]|27.9||||27.9|12.3|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.9||||27.9|8.27|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BCBS UTHCT [115568]|27.9||||27.9|13.11|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.9||||27.9|13.95|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.9||||27.9|13.95|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.9||||27.9|17.58|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.9||||27.9|8.27|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|CIGNA [1260]|CIGNA GWH [126023]|27.9||||27.9|15.35|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|GROUP PENSION ADMIN [1450]|GPA [145000]|27.9||||27.9|19.25|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.9||||27.9|13.95|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.9||||27.9|12.3|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.9||||27.9|8.27|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.9||||27.9|12.3|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.9||||27.9|8.27|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.9||||27.9|8.27|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|PHCS [1780]|PHCS MULTIPLAN [178000]|27.9||||27.9|19.25|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.9||||27.9|8.27|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|Self-pay|Self-pay|27.9||||27.9|9.76|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.9||||27.9|8.27|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.9||||27.9|8.27|1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.9||||27.9||1963.88|8.27
10674|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN 2 % TOPICAL OINTMENT|22 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.9||||27.9||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|AARP [1000]|AARP [100000]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|AETNA [1015]|AETNA [101529]|2846.2||||2846.2|1255.17|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2846.2||||2846.2|843.9|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|BCBS [1155]|BCBS UTHCT [115568]|2846.2||||2846.2|1337.71|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2846.2||||2846.2|1423.1|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2846.2||||2846.2|1423.1|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2846.2||||2846.2|1793.11|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2846.2||||2846.2|843.9|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|CIGNA [1260]|CIGNA GWH [126023]|2846.2||||2846.2|1565.41|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2846.2||||2846.2|1963.88|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2846.2||||2846.2|1423.1|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2846.2||||2846.2|1255.17|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2846.2||||2846.2|843.9|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2846.2||||2846.2|1255.17|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2846.2||||2846.2|843.9|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2846.2||||2846.2|843.9|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2846.2||||2846.2|1963.88|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2846.2||||2846.2|843.9|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|Self-pay|Self-pay|2846.2||||2846.2|996.17|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2846.2||||2846.2|843.9|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2846.2||||2846.2|843.9|1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2846.2||||2846.2||1963.88|8.27
10674|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PILLCAM VIDEO CAP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2846.2||||2846.2||1963.88|8.27
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AARP [1000]|AARP [100000]|600.1||||600.1|270.04|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|600.1||||600.1||414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AETNA [1015]|AETNA [101529]|600.1||||600.1|264.64|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|600.1||||600.1|177.93|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|600.1||||600.1||414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|600.1||||600.1||414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS [1155]|BCBS UTHCT [115568]|600.1||||600.1|282.05|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|600.1||||600.1|300.05|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|600.1||||600.1|300.05|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|600.1||||600.1|378.06|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|600.1||||600.1|177.93|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|600.1||||600.1||414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|CIGNA [1260]|CIGNA GWH [126023]|600.1||||600.1|330.05|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|600.1||||600.1|414.07|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|600.1||||600.1|300.05|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|600.1||||600.1||414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|600.1||||600.1|264.64|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|600.1||||600.1|177.93|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|600.1||||600.1||414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|600.1||||600.1|264.64|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|600.1||||600.1|177.93|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|600.1||||600.1|177.93|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|600.1||||600.1|414.07|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|600.1||||600.1|177.93|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|Self-pay|Self-pay|600.1||||600.1|210.04|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|600.1||||600.1|177.93|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|600.1||||600.1|177.93|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|600.1||||600.1|270.04|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|600.1||||600.1||414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|600.1||||600.1||414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|600.1||||600.1|270.04|414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|600.1||||600.1||414.07|177.93
10676|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|600.1||||600.1||414.07|177.93
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AARP [1000]|AARP [100000]|1310.75||||1310.75|589.84|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1310.75||||1310.75||904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AETNA [1015]|AETNA [101529]|1310.75||||1310.75|578.04|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1310.75||||1310.75|388.64|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1310.75||||1310.75||904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1310.75||||1310.75||904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS [1155]|BCBS UTHCT [115568]|1310.75||||1310.75|616.05|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1310.75||||1310.75|655.38|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1310.75||||1310.75|655.38|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1310.75||||1310.75|825.77|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1310.75||||1310.75|388.64|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1310.75||||1310.75||904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|CIGNA [1260]|CIGNA GWH [126023]|1310.75||||1310.75|720.91|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1310.75||||1310.75|904.42|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1310.75||||1310.75|655.38|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1310.75||||1310.75||904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1310.75||||1310.75|578.04|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1310.75||||1310.75|388.64|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1310.75||||1310.75||904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1310.75||||1310.75|578.04|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1310.75||||1310.75|388.64|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1310.75||||1310.75|388.64|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1310.75||||1310.75|904.42|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1310.75||||1310.75|388.64|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|Self-pay|Self-pay|1310.75||||1310.75|458.76|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1310.75||||1310.75|388.64|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1310.75||||1310.75|388.64|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1310.75||||1310.75|589.84|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1310.75||||1310.75||904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1310.75||||1310.75||904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1310.75||||1310.75|589.84|904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1310.75||||1310.75||904.42|388.64
10677|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SAVORY GUIDE WIRE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1310.75||||1310.75||904.42|388.64
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|3868.8||||3868.8|1261.4|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3868.8||||3868.8|1251.69|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|3868.8||||3868.8|2818.08|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3868.8||||3868.8|1147.1|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3868.8||||3868.8|1239.3|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3868.8||||3868.8|1239.3|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|3868.8||||3868.8|1818.34|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3868.8||||3868.8|0|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3868.8||||3868.8|1934.4|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3868.8||||3868.8|2437.34|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3868.8||||3868.8|1147.1|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3868.8||||3868.8|1239.3|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|3868.8||||3868.8|1934.4|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3868.8||||3868.8|2669.47|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3868.8||||3868.8|147.2|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3868.8||||3868.8|1239.3|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3868.8||||3868.8|2818.08|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3868.8||||3868.8|1147.1|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3868.8||||3868.8|1239.3|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3868.8||||3868.8|2818.08|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3868.8||||3868.8|1147.1|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3868.8||||3868.8|1147.1|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3868.8||||3868.8|2669.47|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3868.8||||3868.8|1147.1|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|3868.8||||3868.8|1354.08|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3868.8||||3868.8|1147.1|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3868.8||||3868.8|1147.1|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3868.8||||3868.8|1261.4|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3868.8||||3868.8|1239.3|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3868.8||||3868.8|1239.3|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3868.8||||3868.8|1261.4|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3868.8||||3868.8|1239.3|2818.08|147.2
106773|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERIBULIN 1 MG/2 ML (0.5 MG/ML) INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3868.8||||3868.8|2478.6|2818.08|147.2
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|1037.36||||1037.36|294|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1037.36||||1037.36|36.81|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|1037.36||||1037.36|388.8|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1037.36||||1037.36|307.58|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1037.36||||1037.36|36.45|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1037.36||||1037.36|36.45|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1037.36||||1037.36|487.56|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1037.36||||1037.36|0|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1037.36||||1037.36|518.68|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1037.36||||1037.36|653.54|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1037.36||||1037.36|307.58|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1037.36||||1037.36|36.45|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1037.36||||1037.36|518.68|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1037.36||||1037.36|715.78|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1037.36||||1037.36|0.53|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1037.36||||1037.36|36.45|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1037.36||||1037.36|388.8|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1037.36||||1037.36|307.58|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1037.36||||1037.36|36.45|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1037.36||||1037.36|388.8|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1037.36||||1037.36|307.58|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1037.36||||1037.36|307.58|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1037.36||||1037.36|715.78|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1037.36||||1037.36|307.58|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|1037.36||||1037.36|363.08|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1037.36||||1037.36|307.58|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1037.36||||1037.36|307.58|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1037.36||||1037.36|294|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1037.36||||1037.36|36.45|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1037.36||||1037.36|36.45|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1037.36||||1037.36|294|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1037.36||||1037.36|36.45|715.78|0.53
106783|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FOSAPREPITANT 150 MG INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1037.36||||1037.36|72.9|715.78|0.53
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|AARP [1000]|AARP [100000]|97.31||||97.31|43.79|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97.31||||97.31||67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|AETNA [1015]|AETNA [101529]|97.31||||97.31|42.92|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97.31||||97.31|28.85|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97.31||||97.31||67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97.31||||97.31||67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|BCBS [1155]|BCBS UTHCT [115568]|97.31||||97.31|45.74|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97.31||||97.31|48.66|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97.31||||97.31|48.66|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97.31||||97.31|61.31|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97.31||||97.31|28.85|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97.31||||97.31||67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|CIGNA [1260]|CIGNA GWH [126023]|97.31||||97.31|53.52|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97.31||||97.31|67.15|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|97.31||||97.31|48.66|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97.31||||97.31||67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97.31||||97.31|42.92|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97.31||||97.31|28.85|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97.31||||97.31||67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97.31||||97.31|42.92|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97.31||||97.31|28.85|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|97.31||||97.31|28.85|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97.31||||97.31|67.15|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97.31||||97.31|28.85|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|Self-pay|Self-pay|97.31||||97.31|34.06|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|97.31||||97.31|28.85|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97.31||||97.31|28.85|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97.31||||97.31|43.79|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|97.31||||97.31||67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|97.31||||97.31||67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97.31||||97.31|43.79|67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97.31||||97.31||67.15|28.85
10680|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER, YUEH CENTESIS NEEDLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97.31||||97.31||67.15|28.85
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|AARP [1000]|AARP [100000]|7722.23||||7722.23|3861.12|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7722.23||||7722.23|2568.11|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|AETNA [1015]|AETNA [101529]|7722.23||||7722.23|5731.2|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7722.23||||7722.23|2289.64|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7722.23||||7722.23|2542.68|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7722.23||||7722.23|2542.68|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|BCBS [1155]|BCBS UTHCT [115568]|7722.23||||7722.23|3629.45|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7722.23||||7722.23|0|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7722.23||||7722.23|3861.12|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7722.23||||7722.23|4865|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7722.23||||7722.23|2289.64|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7722.23||||7722.23|2542.68|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|CIGNA [1260]|CIGNA GWH [126023]|7722.23||||7722.23|3861.12|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7722.23||||7722.23|5328.34|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7722.23||||7722.23|25.14|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7722.23||||7722.23|2542.68|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7722.23||||7722.23|5731.2|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7722.23||||7722.23|2289.64|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7722.23||||7722.23|2542.68|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7722.23||||7722.23|5731.2|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7722.23||||7722.23|2289.64|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7722.23||||7722.23|2289.64|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7722.23||||7722.23|5328.34|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7722.23||||7722.23|2289.64|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|Self-pay|Self-pay|7722.23||||7722.23|2702.78|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7722.23||||7722.23|2289.64|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7722.23||||7722.23|2289.64|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7722.23||||7722.23|3861.12|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7722.23||||7722.23|2542.68|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7722.23||||7722.23|2542.68|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7722.23||||7722.23|3861.12|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7722.23||||7722.23|2542.68|5731.2|25.14
106804|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DENOSUMAB 120 MG/1.7 ML (70 MG/ML) SUBCUTANEOUS SOLUTION|1.7 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7722.23||||7722.23|5085.36|5731.2|25.14
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.65||||4.65|2.05|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.65||||4.65|1.38|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.65||||4.65|2.19|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.65||||4.65|2.33|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.65||||4.65|2.33|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.65||||4.65|2.93|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.65||||4.65|1.38|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.65||||4.65|2.56|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.65||||4.65|3.21|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.65||||4.65|2.33|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.65||||4.65|2.05|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.65||||4.65|1.38|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.65||||4.65|2.05|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.65||||4.65|1.38|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.65||||4.65|1.38|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.65||||4.65|3.21|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.65||||4.65|1.38|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|Self-pay|Self-pay|4.65||||4.65|1.63|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.65||||4.65|1.38|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.65||||4.65|1.38|294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.65||||4.65||294.8|1.38
10685|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NALTREXONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.65||||4.65||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|AARP [1000]|AARP [100000]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|AETNA [1015]|AETNA [101529]|427.25||||427.25|188.42|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|427.25||||427.25|126.68|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|BCBS [1155]|BCBS UTHCT [115568]|427.25||||427.25|200.81|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|427.25||||427.25|213.63|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|427.25||||427.25|213.63|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|427.25||||427.25|269.17|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|427.25||||427.25|126.68|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|CIGNA [1260]|CIGNA GWH [126023]|427.25||||427.25|234.99|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|427.25||||427.25|294.8|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|427.25||||427.25|213.63|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|427.25||||427.25|188.42|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|427.25||||427.25|126.68|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|427.25||||427.25|188.42|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|427.25||||427.25|126.68|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|427.25||||427.25|126.68|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|427.25||||427.25|294.8|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|427.25||||427.25|126.68|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|Self-pay|Self-pay|427.25||||427.25|149.54|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|427.25||||427.25|126.68|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|427.25||||427.25|126.68|294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|427.25||||427.25||294.8|1.38
10685|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX11CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|427.25||||427.25||294.8|1.38
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|AARP [1000]|AARP [100000]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|AETNA [1015]|AETNA [101529]|427.25||||427.25|188.42|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|427.25||||427.25|126.68|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|BCBS [1155]|BCBS UTHCT [115568]|427.25||||427.25|200.81|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|427.25||||427.25|213.63|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|427.25||||427.25|213.63|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|427.25||||427.25|269.17|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|427.25||||427.25|126.68|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|CIGNA [1260]|CIGNA GWH [126023]|427.25||||427.25|234.99|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|427.25||||427.25|294.8|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|427.25||||427.25|213.63|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|427.25||||427.25|188.42|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|427.25||||427.25|126.68|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|427.25||||427.25|188.42|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|427.25||||427.25|126.68|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|427.25||||427.25|126.68|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|427.25||||427.25|294.8|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|427.25||||427.25|126.68|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|Self-pay|Self-pay|427.25||||427.25|149.54|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|427.25||||427.25|126.68|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|427.25||||427.25|126.68|294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|427.25||||427.25||294.8|126.68
10686|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 16GX15CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|427.25||||427.25||294.8|126.68
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|AARP [1000]|AARP [100000]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|AETNA [1015]|AETNA [101529]|419.87||||419.87|185.16|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|419.87||||419.87|124.49|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|BCBS [1155]|BCBS UTHCT [115568]|419.87||||419.87|197.34|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|419.87||||419.87|209.94|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|419.87||||419.87|209.94|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|419.87||||419.87|264.52|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|419.87||||419.87|124.49|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|CIGNA [1260]|CIGNA GWH [126023]|419.87||||419.87|230.93|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|419.87||||419.87|289.71|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|419.87||||419.87|209.94|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|419.87||||419.87|185.16|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|419.87||||419.87|124.49|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|419.87||||419.87|185.16|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|419.87||||419.87|124.49|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|419.87||||419.87|124.49|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|419.87||||419.87|289.71|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|419.87||||419.87|124.49|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|Self-pay|Self-pay|419.87||||419.87|146.95|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|419.87||||419.87|124.49|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|419.87||||419.87|124.49|289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|419.87||||419.87||289.71|124.49
10687|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ACHIEVE BX NEEDLE 18GX11CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|419.87||||419.87||289.71|124.49
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|AARP [1000]|AARP [100000]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|AETNA [1015]|AETNA [101529]|345.21||||345.21|152.24|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|345.21||||345.21|102.36|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|BCBS [1155]|BCBS UTHCT [115568]|345.21||||345.21|162.25|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|345.21||||345.21|172.61|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|345.21||||345.21|172.61|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|345.21||||345.21|217.48|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|345.21||||345.21|102.36|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|CIGNA [1260]|CIGNA GWH [126023]|345.21||||345.21|189.87|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|345.21||||345.21|238.2|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|345.21||||345.21|172.61|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|345.21||||345.21|152.24|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|345.21||||345.21|102.36|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|345.21||||345.21|152.24|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|345.21||||345.21|102.36|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|345.21||||345.21|102.36|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|345.21||||345.21|238.2|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|345.21||||345.21|102.36|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|Self-pay|Self-pay|345.21||||345.21|120.82|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|345.21||||345.21|102.36|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|345.21||||345.21|102.36|238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|345.21||||345.21||238.2|102.36
10688|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARD BX NEEDL 18GX20CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|345.21||||345.21||238.2|102.36
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|AARP [1000]|AARP [100000]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|AETNA [1015]|AETNA [101529]|112.2||||112.2|49.48|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|112.2||||112.2|33.27|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|BCBS [1155]|BCBS UTHCT [115568]|112.2||||112.2|52.73|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|112.2||||112.2|56.1|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|112.2||||112.2|56.1|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|112.2||||112.2|70.69|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|112.2||||112.2|33.27|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|CIGNA [1260]|CIGNA GWH [126023]|112.2||||112.2|61.71|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|112.2||||112.2|77.42|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|112.2||||112.2|56.1|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|112.2||||112.2|49.48|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|112.2||||112.2|33.27|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|112.2||||112.2|49.48|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|112.2||||112.2|33.27|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|112.2||||112.2|33.27|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|112.2||||112.2|77.42|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|112.2||||112.2|33.27|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|Self-pay|Self-pay|112.2||||112.2|39.27|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|112.2||||112.2|33.27|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|112.2||||112.2|33.27|77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|112.2||||112.2||77.42|33.27
10689|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BX TRAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|112.2||||112.2||77.42|33.27
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|AARP [1000]|AARP [100000]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|AETNA [1015]|AETNA [101529]|432.03||||432.03|190.53|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|432.03||||432.03|128.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|BCBS [1155]|BCBS UTHCT [115568]|432.03||||432.03|203.05|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|432.03||||432.03|216.02|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|432.03||||432.03|216.02|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|432.03||||432.03|272.18|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|432.03||||432.03|128.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|CIGNA [1260]|CIGNA GWH [126023]|432.03||||432.03|237.62|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|432.03||||432.03|298.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|432.03||||432.03|216.02|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|432.03||||432.03|190.53|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|432.03||||432.03|128.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|432.03||||432.03|190.53|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|432.03||||432.03|128.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|432.03||||432.03|128.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|432.03||||432.03|298.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|432.03||||432.03|128.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|Self-pay|Self-pay|432.03||||432.03|151.21|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|432.03||||432.03|128.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|432.03||||432.03|128.1|298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|432.03||||432.03||298.1|128.1
10690|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ULTRA CLIP II TISSUE MARKERS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|432.03||||432.03||298.1|128.1
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|AARP [1000]|AARP [100000]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|AETNA [1015]|AETNA [101529]|595.74||||595.74|262.72|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|595.74||||595.74|176.64|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|BCBS [1155]|BCBS UTHCT [115568]|595.74||||595.74|280|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|595.74||||595.74|297.87|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|595.74||||595.74|297.87|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|595.74||||595.74|375.32|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|595.74||||595.74|176.64|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|CIGNA [1260]|CIGNA GWH [126023]|595.74||||595.74|327.66|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|595.74||||595.74|411.06|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|595.74||||595.74|297.87|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|595.74||||595.74|262.72|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|595.74||||595.74|176.64|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|595.74||||595.74|262.72|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|595.74||||595.74|176.64|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|595.74||||595.74|176.64|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|595.74||||595.74|411.06|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|595.74||||595.74|176.64|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|Self-pay|Self-pay|595.74||||595.74|208.51|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|595.74||||595.74|176.64|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|595.74||||595.74|176.64|411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|595.74||||595.74||411.06|176.64
10691|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|14 x 10 BIOPSY NEEDLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|595.74||||595.74||411.06|176.64
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|AARP [1000]|AARP [100000]|363||||363|163.35|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|363||||363||250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|AETNA [1015]|AETNA [101529]|363||||363|160.08|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|363||||363|107.63|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|363||||363||250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|363||||363||250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|BCBS [1155]|BCBS UTHCT [115568]|363||||363|170.61|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|363||||363|181.5|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|363||||363|181.5|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|363||||363|228.69|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|363||||363|107.63|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|363||||363||250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|CIGNA [1260]|CIGNA GWH [126023]|363||||363|199.65|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|363||||363|250.47|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|363||||363|181.5|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|363||||363||250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|363||||363|160.08|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|363||||363|107.63|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|363||||363||250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|363||||363|160.08|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|363||||363|107.63|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|363||||363|107.63|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|363||||363|250.47|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|363||||363|107.63|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|Self-pay|Self-pay|363||||363|127.05|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|363||||363|107.63|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|363||||363|107.63|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|363||||363|163.35|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|363||||363||250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|363||||363||250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|363||||363|163.35|250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|363||||363||250.47|107.63
10693|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DM DRAINAGE CATH 10.2 F x 15CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|363||||363||250.47|107.63
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|AARP [1000]|AARP [100000]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|AETNA [1015]|AETNA [101529]|516.13||||516.13|227.61|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|516.13||||516.13|153.03|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|BCBS [1155]|BCBS UTHCT [115568]|516.13||||516.13|242.58|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|516.13||||516.13|258.06|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|516.13||||516.13|258.06|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|516.13||||516.13|325.16|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|516.13||||516.13|153.03|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|CIGNA [1260]|CIGNA GWH [126023]|516.13||||516.13|283.87|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|516.13||||516.13|356.13|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|516.13||||516.13|258.06|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|516.13||||516.13|227.61|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|516.13||||516.13|153.03|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|516.13||||516.13|227.61|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|516.13||||516.13|153.03|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|516.13||||516.13|153.03|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|516.13||||516.13|356.13|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|516.13||||516.13|153.03|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|Self-pay|Self-pay|516.13||||516.13|180.65|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|516.13||||516.13|153.03|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|516.13||||516.13|153.03|356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|516.13||||516.13||356.13|153.03
10702|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|IODOSORB GEL 40GM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|516.13||||516.13||356.13|153.03
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|AARP [1000]|AARP [100000]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|AETNA [1015]|AETNA [101529]|1451.4||||1451.4|640.07|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1451.4||||1451.4|430.34|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|BCBS [1155]|BCBS UTHCT [115568]|1451.4||||1451.4|682.16|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1451.4||||1451.4|725.7|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1451.4||||1451.4|725.7|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1451.4||||1451.4|914.38|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1451.4||||1451.4|430.34|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|CIGNA [1260]|CIGNA GWH [126023]|1451.4||||1451.4|798.27|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1451.4||||1451.4|1001.47|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1451.4||||1451.4|725.7|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1451.4||||1451.4|640.07|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1451.4||||1451.4|430.34|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1451.4||||1451.4|640.07|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1451.4||||1451.4|430.34|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1451.4||||1451.4|430.34|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1451.4||||1451.4|1001.47|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1451.4||||1451.4|430.34|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|Self-pay|Self-pay|1451.4||||1451.4|507.99|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1451.4||||1451.4|430.34|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1451.4||||1451.4|430.34|1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1451.4||||1451.4||1001.47|430.34
10704|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET 8FR - 24FR .038 WIRE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1451.4||||1451.4||1001.47|430.34
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|AARP [1000]|AARP [100000]|976.38||||976.38|439.37|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|976.38||||976.38||673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|AETNA [1015]|AETNA [101529]|976.38||||976.38|430.58|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|976.38||||976.38|289.5|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|976.38||||976.38||673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|976.38||||976.38||673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|BCBS [1155]|BCBS UTHCT [115568]|976.38||||976.38|458.9|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|976.38||||976.38|488.19|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|976.38||||976.38|488.19|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|976.38||||976.38|615.12|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|976.38||||976.38|289.5|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|976.38||||976.38||673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|CIGNA [1260]|CIGNA GWH [126023]|976.38||||976.38|537.01|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|976.38||||976.38|673.7|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|976.38||||976.38|488.19|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|976.38||||976.38||673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|976.38||||976.38|430.58|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|976.38||||976.38|289.5|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|976.38||||976.38||673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|976.38||||976.38|430.58|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|976.38||||976.38|289.5|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|976.38||||976.38|289.5|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|976.38||||976.38|673.7|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|976.38||||976.38|289.5|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|Self-pay|Self-pay|976.38||||976.38|341.74|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|976.38||||976.38|289.5|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|976.38||||976.38|289.5|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|976.38||||976.38|439.37|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|976.38||||976.38||673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|976.38||||976.38||673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|976.38||||976.38|439.37|673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|976.38||||976.38||673.7|289.5
10705|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX SET WAYNE SELDINGER SET 14 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|976.38||||976.38||673.7|289.5
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|AARP [1000]|AARP [100000]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|AETNA [1015]|AETNA [101529]|1231.04||||1231.04|542.89|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1231.04||||1231.04|365|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|BCBS [1155]|BCBS UTHCT [115568]|1231.04||||1231.04|578.59|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1231.04||||1231.04|615.52|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1231.04||||1231.04|615.52|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1231.04||||1231.04|775.55|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1231.04||||1231.04|365|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|CIGNA [1260]|CIGNA GWH [126023]|1231.04||||1231.04|677.07|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1231.04||||1231.04|849.41|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1231.04||||1231.04|615.52|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1231.04||||1231.04|542.89|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1231.04||||1231.04|365|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1231.04||||1231.04|542.89|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1231.04||||1231.04|365|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1231.04||||1231.04|365|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1231.04||||1231.04|849.41|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1231.04||||1231.04|365|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|Self-pay|Self-pay|1231.04||||1231.04|430.87|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1231.04||||1231.04|365|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1231.04||||1231.04|365|849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1231.04||||1231.04||849.41|365
10707|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|DRESSING PREVENA PEEL AND PLACE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1231.04||||1231.04||849.41|365
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|AARP [1000]|AARP [100000]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|AETNA [1015]|AETNA [101529]|50.19||||50.19|22.13|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.19||||50.19|14.88|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|BCBS [1155]|BCBS UTHCT [115568]|50.19||||50.19|23.59|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.19||||50.19|25.1|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.19||||50.19|25.1|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.19||||50.19|31.62|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.19||||50.19|14.88|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|CIGNA [1260]|CIGNA GWH [126023]|50.19||||50.19|27.6|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|50.19||||50.19|34.63|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50.19||||50.19|25.1|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.19||||50.19|22.13|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.19||||50.19|14.88|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.19||||50.19|22.13|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.19||||50.19|14.88|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|50.19||||50.19|14.88|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|50.19||||50.19|34.63|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.19||||50.19|14.88|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|Self-pay|Self-pay|50.19||||50.19|17.57|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50.19||||50.19|14.88|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.19||||50.19|14.88|34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.19||||50.19||34.63|14.88
10710|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"BIOPATCH 1"" 4MM"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.19||||50.19||34.63|14.88
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|5.53||||5.53|2.44|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.53||||5.53|1.64|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|5.53||||5.53|2.6|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.53||||5.53|2.77|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.53||||5.53|2.77|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.53||||5.53|3.48|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.53||||5.53|1.64|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|5.53||||5.53|3.04|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.53||||5.53|3.82|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.53||||5.53|2.77|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.53||||5.53|2.44|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.53||||5.53|1.64|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.53||||5.53|2.44|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.53||||5.53|1.64|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.53||||5.53|1.64|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.53||||5.53|3.82|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.53||||5.53|1.64|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|Self-pay|Self-pay|5.53||||5.53|1.94|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.53||||5.53|1.64|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.53||||5.53|1.64|46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.53||||5.53||46.76|1.64
10712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICARDIPINE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.53||||5.53||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|AARP [1000]|AARP [100000]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|AETNA [1015]|AETNA [101529]|67.77||||67.77|29.89|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|67.77||||67.77|20.09|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|BCBS [1155]|BCBS UTHCT [115568]|67.77||||67.77|31.85|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|67.77||||67.77|33.89|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|67.77||||67.77|33.89|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|67.77||||67.77|42.7|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|67.77||||67.77|20.09|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|CIGNA [1260]|CIGNA GWH [126023]|67.77||||67.77|37.27|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|67.77||||67.77|46.76|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|67.77||||67.77|33.89|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|67.77||||67.77|29.89|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|67.77||||67.77|20.09|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|67.77||||67.77|29.89|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|67.77||||67.77|20.09|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|67.77||||67.77|20.09|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|67.77||||67.77|46.76|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|67.77||||67.77|20.09|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|Self-pay|Self-pay|67.77||||67.77|23.72|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|67.77||||67.77|20.09|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|67.77||||67.77|20.09|46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|67.77||||67.77||46.76|1.64
10712|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER FEMALE EXTERNAL PUREWICK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|67.77||||67.77||46.76|1.64
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|AARP [1000]|AARP [100000]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|AETNA [1015]|AETNA [101529]|35.78||||35.78|15.78|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.78||||35.78|10.61|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|BCBS [1155]|BCBS UTHCT [115568]|35.78||||35.78|16.81|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.78||||35.78|17.89|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.78||||35.78|17.89|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.78||||35.78|22.54|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.78||||35.78|10.61|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|CIGNA [1260]|CIGNA GWH [126023]|35.78||||35.78|19.68|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|35.78||||35.78|24.68|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35.78||||35.78|17.89|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.78||||35.78|15.78|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.78||||35.78|10.61|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.78||||35.78|15.78|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.78||||35.78|10.61|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|35.78||||35.78|10.61|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|35.78||||35.78|24.68|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.78||||35.78|10.61|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|Self-pay|Self-pay|35.78||||35.78|12.53|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35.78||||35.78|10.61|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.78||||35.78|10.61|24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.78||||35.78||24.68|10.61
10713|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"NEEDLE HUBER SAFESTEP 19 GA X 1"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.78||||35.78||24.68|10.61
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|AARP [1000]|AARP [100000]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|AETNA [1015]|AETNA [101529]|87.59||||87.59|38.63|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|87.59||||87.59|25.97|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|BCBS [1155]|BCBS UTHCT [115568]|87.59||||87.59|41.17|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|87.59||||87.59|43.8|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|87.59||||87.59|43.8|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|87.59||||87.59|55.18|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|87.59||||87.59|25.97|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|CIGNA [1260]|CIGNA GWH [126023]|87.59||||87.59|48.17|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|87.59||||87.59|60.44|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|87.59||||87.59|43.8|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|87.59||||87.59|38.63|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|87.59||||87.59|25.97|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|87.59||||87.59|38.63|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|87.59||||87.59|25.97|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|87.59||||87.59|25.97|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|87.59||||87.59|60.44|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|87.59||||87.59|25.97|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|Self-pay|Self-pay|87.59||||87.59|30.66|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|87.59||||87.59|25.97|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|87.59||||87.59|25.97|60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|87.59||||87.59||60.44|25.97
10714|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SUCTION SYSTEMTRACH CLOSED 12 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|87.59||||87.59||60.44|25.97
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|AARP [1000]|AARP [100000]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|AETNA [1015]|AETNA [101529]|175.95||||175.95|77.59|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175.95||||175.95|52.17|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|BCBS [1155]|BCBS UTHCT [115568]|175.95||||175.95|82.7|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175.95||||175.95|87.97|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175.95||||175.95|87.97|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175.95||||175.95|110.85|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175.95||||175.95|52.17|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|CIGNA [1260]|CIGNA GWH [126023]|175.95||||175.95|96.77|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|GROUP PENSION ADMIN [1450]|GPA [145000]|175.95||||175.95|121.4|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|175.95||||175.95|87.97|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175.95||||175.95|77.59|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175.95||||175.95|52.17|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175.95||||175.95|77.59|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175.95||||175.95|52.17|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|175.95||||175.95|52.17|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|PHCS [1780]|PHCS MULTIPLAN [178000]|175.95||||175.95|121.4|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175.95||||175.95|52.17|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|Self-pay|Self-pay|175.95||||175.95|61.58|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|175.95||||175.95|52.17|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175.95||||175.95|52.17|121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175.95||||175.95||121.4|52.17
10716|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"ARTERIAL CATHETER KIT NEEDLE 19GAX2 1/4"" CATHETER 18GAX6"""|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175.95||||175.95||121.4|52.17
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AARP [1000]|AARP [100000]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AETNA [1015]|AETNA [101529]|0.71||||0.71|0.31|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.71||||0.71|0.21|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BCBS UTHCT [115568]|0.71||||0.71|0.33|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.71||||0.71|0.36|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.71||||0.71|0.36|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.71||||0.71|0.45|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.71||||0.71|0.21|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|CIGNA [1260]|CIGNA GWH [126023]|0.71||||0.71|0.39|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|0.71||||0.71|0.49|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.71||||0.71|0.36|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.71||||0.71|0.31|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.71||||0.71|0.21|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.71||||0.71|0.31|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.71||||0.71|0.21|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.71||||0.71|0.21|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|0.71||||0.71|0.49|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.71||||0.71|0.21|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|Self-pay|Self-pay|0.71||||0.71|0.25|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.71||||0.71|0.21|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.71||||0.71|0.21|601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.71||||0.71||601.71|0.21
10717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE (POLACRILEX) 2 MG GUM|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.71||||0.71||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|AARP [1000]|AARP [100000]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|AETNA [1015]|AETNA [101529]|872.05||||872.05|384.57|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|872.05||||872.05|258.56|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|BCBS [1155]|BCBS UTHCT [115568]|872.05||||872.05|409.86|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|872.05||||872.05|436.03|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|872.05||||872.05|436.03|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|872.05||||872.05|549.39|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|872.05||||872.05|258.56|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|CIGNA [1260]|CIGNA GWH [126023]|872.05||||872.05|479.63|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|872.05||||872.05|601.71|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|872.05||||872.05|436.03|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|872.05||||872.05|384.57|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|872.05||||872.05|258.56|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|872.05||||872.05|384.57|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|872.05||||872.05|258.56|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|872.05||||872.05|258.56|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|872.05||||872.05|601.71|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|872.05||||872.05|258.56|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|Self-pay|Self-pay|872.05||||872.05|305.22|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|872.05||||872.05|258.56|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|872.05||||872.05|258.56|601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|872.05||||872.05||601.71|0.21
10717|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BONE MARROW BIOPSY TRAY ONCONTROL 102MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|872.05||||872.05||601.71|0.21
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|AARP [1000]|AARP [100000]|967.33||||967.33|435.3|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|967.33||||967.33||667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|AETNA [1015]|AETNA [101529]|967.33||||967.33|426.59|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|967.33||||967.33|286.81|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|967.33||||967.33||667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|967.33||||967.33||667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|BCBS [1155]|BCBS UTHCT [115568]|967.33||||967.33|454.65|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|967.33||||967.33|483.67|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|967.33||||967.33|483.67|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|967.33||||967.33|609.42|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|967.33||||967.33|286.81|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|967.33||||967.33||667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|CIGNA [1260]|CIGNA GWH [126023]|967.33||||967.33|532.03|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|967.33||||967.33|667.46|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|967.33||||967.33|483.67|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|967.33||||967.33||667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|967.33||||967.33|426.59|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|967.33||||967.33|286.81|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|967.33||||967.33||667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|967.33||||967.33|426.59|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|967.33||||967.33|286.81|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|967.33||||967.33|286.81|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|967.33||||967.33|667.46|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|967.33||||967.33|286.81|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|Self-pay|Self-pay|967.33||||967.33|338.56|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|967.33||||967.33|286.81|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|967.33||||967.33|286.81|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|967.33||||967.33|435.3|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|967.33||||967.33||667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|967.33||||967.33||667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|967.33||||967.33|435.3|667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|967.33||||967.33||667.46|286.81
10718|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 16 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|967.33||||967.33||667.46|286.81
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.24||||1.24|0.55|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.24||||1.24|0.37|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.24||||1.24|0.58|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.24||||1.24|0.62|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.24||||1.24|0.62|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.24||||1.24|0.78|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.24||||1.24|0.37|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.24||||1.24|0.68|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.24||||1.24|0.86|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.24||||1.24|0.62|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.24||||1.24|0.55|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.24||||1.24|0.37|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.24||||1.24|0.55|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.24||||1.24|0.37|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.24||||1.24|0.37|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.24||||1.24|0.86|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.24||||1.24|0.37|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|1.24||||1.24|0.43|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.24||||1.24|0.37|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.24||||1.24|0.37|667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.24||||1.24||667.46|0.37
10719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.24||||1.24||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|AARP [1000]|AARP [100000]|967.33||||967.33|435.3|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|967.33||||967.33||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|AETNA [1015]|AETNA [101529]|967.33||||967.33|426.59|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|967.33||||967.33|286.81|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|967.33||||967.33||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|967.33||||967.33||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|BCBS [1155]|BCBS UTHCT [115568]|967.33||||967.33|454.65|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|967.33||||967.33|483.67|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|967.33||||967.33|483.67|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|967.33||||967.33|609.42|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|967.33||||967.33|286.81|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|967.33||||967.33||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|CIGNA [1260]|CIGNA GWH [126023]|967.33||||967.33|532.03|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|967.33||||967.33|667.46|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|967.33||||967.33|483.67|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|967.33||||967.33||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|967.33||||967.33|426.59|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|967.33||||967.33|286.81|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|967.33||||967.33||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|967.33||||967.33|426.59|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|967.33||||967.33|286.81|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|967.33||||967.33|286.81|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|967.33||||967.33|667.46|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|967.33||||967.33|286.81|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|Self-pay|Self-pay|967.33||||967.33|338.56|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|967.33||||967.33|286.81|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|967.33||||967.33|286.81|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|967.33||||967.33|435.3|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|967.33||||967.33||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|967.33||||967.33||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|967.33||||967.33|435.3|667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|967.33||||967.33||667.46|0.37
10719|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 20 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|967.33||||967.33||667.46|0.37
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|AARP [1000]|AARP [100000]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|AETNA [1015]|AETNA [101529]|157.88||||157.88|69.63|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|157.88||||157.88|46.81|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|BCBS [1155]|BCBS UTHCT [115568]|157.88||||157.88|74.21|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|157.88||||157.88|78.94|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|157.88||||157.88|78.94|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|157.88||||157.88|99.47|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|157.88||||157.88|46.81|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|CIGNA [1260]|CIGNA GWH [126023]|157.88||||157.88|86.84|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|157.88||||157.88|108.94|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|157.88||||157.88|78.94|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|157.88||||157.88|69.63|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|157.88||||157.88|46.81|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|157.88||||157.88|69.63|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|157.88||||157.88|46.81|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|157.88||||157.88|46.81|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|157.88||||157.88|108.94|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|157.88||||157.88|46.81|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|Self-pay|Self-pay|157.88||||157.88|55.26|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|157.88||||157.88|46.81|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|157.88||||157.88|46.81|108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|157.88||||157.88||108.94|46.81
10723|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSOR BRAIN MONITORING BIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|157.88||||157.88||108.94|46.81
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AARP [1000]|AARP [100000]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AETNA [1015]|AETNA [101529]|69.75||||69.75|30.76|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69.75||||69.75|20.68|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BCBS UTHCT [115568]|69.75||||69.75|32.78|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69.75||||69.75|34.88|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69.75||||69.75|34.88|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69.75||||69.75|43.94|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69.75||||69.75|20.68|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA [1260]|CIGNA GWH [126023]|69.75||||69.75|38.36|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|69.75||||69.75|48.13|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|69.75||||69.75|34.88|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.75||||69.75|30.76|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69.75||||69.75|20.68|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69.75||||69.75|30.76|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69.75||||69.75|20.68|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|69.75||||69.75|20.68|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|69.75||||69.75|48.13|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69.75||||69.75|20.68|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|Self-pay|Self-pay|69.75||||69.75|24.41|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|69.75||||69.75|20.68|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69.75||||69.75|20.68|48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69.75||||69.75||48.13|20.68
10726|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 100 MG/250 ML (400 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69.75||||69.75||48.13|20.68
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|AARP [1000]|AARP [100000]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|AETNA [1015]|AETNA [101529]|23.91||||23.91|10.54|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.91||||23.91|7.09|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|BCBS [1155]|BCBS UTHCT [115568]|23.91||||23.91|11.24|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.91||||23.91|11.95|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.91||||23.91|11.95|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.91||||23.91|15.06|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.91||||23.91|7.09|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|CIGNA [1260]|CIGNA GWH [126023]|23.91||||23.91|13.15|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23.91||||23.91|16.5|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.91||||23.91|11.95|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.91||||23.91|10.54|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.91||||23.91|7.09|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.91||||23.91|10.54|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.91||||23.91|7.09|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.91||||23.91|7.09|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23.91||||23.91|16.5|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.91||||23.91|7.09|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|Self-pay|Self-pay|23.91||||23.91|8.37|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.91||||23.91|7.09|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.91||||23.91|7.09|16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.91||||23.91||16.5|7.09
10732|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SECONDARY BLOOD IV TUBING PLUM MACROBORE 200 MICR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.91||||23.91||16.5|7.09
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|AARP [1000]|AARP [100000]|921.27||||921.27|414.57|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|921.27||||921.27||635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|AETNA [1015]|AETNA [101529]|921.27||||921.27|406.28|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|921.27||||921.27|273.16|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|921.27||||921.27||635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|921.27||||921.27||635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|BCBS [1155]|BCBS UTHCT [115568]|921.27||||921.27|433|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|921.27||||921.27|460.64|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|921.27||||921.27|460.64|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|921.27||||921.27|580.4|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|921.27||||921.27|273.16|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|921.27||||921.27||635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|CIGNA [1260]|CIGNA GWH [126023]|921.27||||921.27|506.7|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|921.27||||921.27|635.68|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|921.27||||921.27|460.64|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|921.27||||921.27||635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|921.27||||921.27|406.28|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|921.27||||921.27|273.16|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|921.27||||921.27||635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|921.27||||921.27|406.28|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|921.27||||921.27|273.16|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|921.27||||921.27|273.16|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|921.27||||921.27|635.68|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|921.27||||921.27|273.16|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|Self-pay|Self-pay|921.27||||921.27|322.44|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|921.27||||921.27|273.16|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|921.27||||921.27|273.16|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|921.27||||921.27|414.57|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|921.27||||921.27||635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|921.27||||921.27||635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|921.27||||921.27|414.57|635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|921.27||||921.27||635.68|273.16
10736|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 24 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|921.27||||921.27||635.68|273.16
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|AARP [1000]|AARP [100000]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|AETNA [1015]|AETNA [101529]|936.25||||936.25|412.89|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|936.25||||936.25|277.6|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|BCBS [1155]|BCBS UTHCT [115568]|936.25||||936.25|440.04|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|936.25||||936.25|468.13|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|936.25||||936.25|468.13|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|936.25||||936.25|589.84|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|936.25||||936.25|277.6|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|CIGNA [1260]|CIGNA GWH [126023]|936.25||||936.25|514.94|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|936.25||||936.25|646.01|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|936.25||||936.25|468.13|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|936.25||||936.25|412.89|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|936.25||||936.25|277.6|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|936.25||||936.25|412.89|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|936.25||||936.25|277.6|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|936.25||||936.25|277.6|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|936.25||||936.25|646.01|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|936.25||||936.25|277.6|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|Self-pay|Self-pay|936.25||||936.25|327.69|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|936.25||||936.25|277.6|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|936.25||||936.25|277.6|646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|936.25||||936.25||646.01|277.6
10737|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|THAL-QUICK CHEST TUBE TRAY 28 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|936.25||||936.25||646.01|277.6
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|AARP [1000]|AARP [100000]|456.17||||456.17|205.28|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|456.17||||456.17||314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|AETNA [1015]|AETNA [101529]|456.17||||456.17|201.17|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|456.17||||456.17|135.25|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|456.17||||456.17||314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|456.17||||456.17||314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|BCBS [1155]|BCBS UTHCT [115568]|456.17||||456.17|214.4|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|456.17||||456.17|228.09|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|456.17||||456.17|228.09|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|456.17||||456.17|287.39|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|456.17||||456.17|135.25|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|456.17||||456.17||314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|CIGNA [1260]|CIGNA GWH [126023]|456.17||||456.17|250.89|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|456.17||||456.17|314.76|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|456.17||||456.17|228.09|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|456.17||||456.17||314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|456.17||||456.17|201.17|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|456.17||||456.17|135.25|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|456.17||||456.17||314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|456.17||||456.17|201.17|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|456.17||||456.17|135.25|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|456.17||||456.17|135.25|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|456.17||||456.17|314.76|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|456.17||||456.17|135.25|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|Self-pay|Self-pay|456.17||||456.17|159.66|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|456.17||||456.17|135.25|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|456.17||||456.17|135.25|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|456.17||||456.17|205.28|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|456.17||||456.17||314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|456.17||||456.17||314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|456.17||||456.17|205.28|314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|456.17||||456.17||314.76|135.25
10738|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PNEUMOTHORAX ASPIRATION SET SIMPLE 14 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|456.17||||456.17||314.76|135.25
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|AARP [1000]|AARP [100000]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|AETNA [1015]|AETNA [101529]|1369.28||||1369.28|603.85|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1369.28||||1369.28|405.99|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|BCBS [1155]|BCBS UTHCT [115568]|1369.28||||1369.28|643.56|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1369.28||||1369.28|684.64|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1369.28||||1369.28|684.64|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1369.28||||1369.28|862.65|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1369.28||||1369.28|405.99|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|CIGNA [1260]|CIGNA GWH [126023]|1369.28||||1369.28|753.1|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1369.28||||1369.28|944.8|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1369.28||||1369.28|684.64|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1369.28||||1369.28|603.85|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1369.28||||1369.28|405.99|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1369.28||||1369.28|603.85|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1369.28||||1369.28|405.99|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1369.28||||1369.28|405.99|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1369.28||||1369.28|944.8|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1369.28||||1369.28|405.99|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|Self-pay|Self-pay|1369.28||||1369.28|479.25|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1369.28||||1369.28|405.99|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1369.28||||1369.28|405.99|944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1369.28||||1369.28||944.8|405.99
10739|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|URETHRAL DILATOR SET S-CURVE W/AQ HYDROPHILIC COATING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1369.28||||1369.28||944.8|405.99
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|AARP [1000]|AARP [100000]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|AETNA [1015]|AETNA [101529]|46.94||||46.94|20.7|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.94||||46.94|13.92|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|BCBS [1155]|BCBS UTHCT [115568]|46.94||||46.94|22.06|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.94||||46.94|23.47|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.94||||46.94|23.47|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.94||||46.94|29.57|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.94||||46.94|13.92|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|CIGNA [1260]|CIGNA GWH [126023]|46.94||||46.94|25.82|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|GROUP PENSION ADMIN [1450]|GPA [145000]|46.94||||46.94|32.39|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|46.94||||46.94|23.47|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.94||||46.94|20.7|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.94||||46.94|13.92|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.94||||46.94|20.7|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.94||||46.94|13.92|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|46.94||||46.94|13.92|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|PHCS [1780]|PHCS MULTIPLAN [178000]|46.94||||46.94|32.39|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.94||||46.94|13.92|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|Self-pay|Self-pay|46.94||||46.94|16.43|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|46.94||||46.94|13.92|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.94||||46.94|13.92|32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.94||||46.94||32.39|13.92
10747|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 6.0 28. SIMS PORTEX #340060|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.94||||46.94||32.39|13.92
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|AARP [1000]|AARP [100000]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|AETNA [1015]|AETNA [101529]|15.91||||15.91|7.02|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.91||||15.91|4.72|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|BCBS [1155]|BCBS UTHCT [115568]|15.91||||15.91|7.48|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.91||||15.91|7.95|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.91||||15.91|7.95|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.91||||15.91|10.02|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.91||||15.91|4.72|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|CIGNA [1260]|CIGNA GWH [126023]|15.91||||15.91|8.75|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|15.91||||15.91|10.98|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.91||||15.91|7.95|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.91||||15.91|7.02|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.91||||15.91|4.72|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.91||||15.91|7.02|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.91||||15.91|4.72|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.91||||15.91|4.72|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|15.91||||15.91|10.98|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.91||||15.91|4.72|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|Self-pay|Self-pay|15.91||||15.91|5.57|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.91||||15.91|4.72|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.91||||15.91|4.72|10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.91||||15.91||10.98|4.72
10748|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY NASOPHARYNGEAL 8.0 32FR. #NA32FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.91||||15.91||10.98|4.72
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|AARP [1000]|AARP [100000]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|AETNA [1015]|AETNA [101529]|14.15||||14.15|6.24|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.15||||14.15|4.2|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS [1155]|BCBS UTHCT [115568]|14.15||||14.15|6.65|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.15||||14.15|7.08|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.15||||14.15|7.08|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.15||||14.15|8.92|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.15||||14.15|4.2|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|CIGNA [1260]|CIGNA GWH [126023]|14.15||||14.15|7.78|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14.15||||14.15|9.76|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.15||||14.15|7.08|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.15||||14.15|6.24|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.15||||14.15|4.2|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.15||||14.15|6.24|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.15||||14.15|4.2|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.15||||14.15|4.2|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14.15||||14.15|9.76|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.15||||14.15|4.2|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|Self-pay|Self-pay|14.15||||14.15|4.95|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.15||||14.15|4.2|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.15||||14.15|4.2|9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.15||||14.15||9.76|4.2
10750|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 8 1/2 MURPHY W/CUFF ORAL STERIL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.15||||14.15||9.76|4.2
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|AARP [1000]|AARP [100000]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|AETNA [1015]|AETNA [101529]|48.17||||48.17|21.24|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48.17||||48.17|14.28|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|BCBS [1155]|BCBS UTHCT [115568]|48.17||||48.17|22.64|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48.17||||48.17|24.08|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48.17||||48.17|24.08|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48.17||||48.17|30.35|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48.17||||48.17|14.28|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|CIGNA [1260]|CIGNA GWH [126023]|48.17||||48.17|26.49|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|GROUP PENSION ADMIN [1450]|GPA [145000]|48.17||||48.17|33.24|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|48.17||||48.17|24.08|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48.17||||48.17|21.24|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48.17||||48.17|14.28|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48.17||||48.17|21.24|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48.17||||48.17|14.28|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|48.17||||48.17|14.28|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|PHCS [1780]|PHCS MULTIPLAN [178000]|48.17||||48.17|33.24|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48.17||||48.17|14.28|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|Self-pay|Self-pay|48.17||||48.17|16.86|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|48.17||||48.17|14.28|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48.17||||48.17|14.28|33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48.17||||48.17||33.24|14.28
10752|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 5|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|AARP [1000]|AARP [100000]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|AETNA [1015]|AETNA [101529]|48.17||||48.17|21.24|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48.17||||48.17|14.28|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|BCBS [1155]|BCBS UTHCT [115568]|48.17||||48.17|22.64|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48.17||||48.17|24.08|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48.17||||48.17|24.08|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48.17||||48.17|30.35|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48.17||||48.17|14.28|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|CIGNA [1260]|CIGNA GWH [126023]|48.17||||48.17|26.49|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|48.17||||48.17|33.24|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|48.17||||48.17|24.08|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48.17||||48.17|21.24|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48.17||||48.17|14.28|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48.17||||48.17|21.24|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48.17||||48.17|14.28|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|48.17||||48.17|14.28|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|48.17||||48.17|33.24|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48.17||||48.17|14.28|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|Self-pay|Self-pay|48.17||||48.17|16.86|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|48.17||||48.17|14.28|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48.17||||48.17|14.28|33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48.17||||48.17||33.24|14.28
10753|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LARYNGEAL MASK AIRWAY SILICONE SIZE 3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48.17||||48.17||33.24|14.28
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|AARP [1000]|AARP [100000]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|AETNA [1015]|AETNA [101529]|14.06||||14.06|6.2|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.06||||14.06|4.17|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS [1155]|BCBS UTHCT [115568]|14.06||||14.06|6.61|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.06||||14.06|7.03|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.06||||14.06|7.03|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.06||||14.06|8.86|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.06||||14.06|4.17|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|CIGNA [1260]|CIGNA GWH [126023]|14.06||||14.06|7.74|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14.06||||14.06|9.7|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.06||||14.06|7.03|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.06||||14.06|6.2|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.06||||14.06|4.17|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.06||||14.06|6.2|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.06||||14.06|4.17|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.06||||14.06|4.17|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14.06||||14.06|9.7|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.06||||14.06|4.17|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|Self-pay|Self-pay|14.06||||14.06|4.92|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.06||||14.06|4.17|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.06||||14.06|4.17|9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.06||||14.06||9.7|4.17
10754|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL SIZE 6 1/2 MURPHY W/CUFF ORAL STERIL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.06||||14.06||9.7|4.17
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|AARP [1000]|AARP [100000]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|AETNA [1015]|AETNA [101529]|14.15||||14.15|6.24|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.15||||14.15|4.2|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|BCBS [1155]|BCBS UTHCT [115568]|14.15||||14.15|6.65|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.15||||14.15|7.08|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.15||||14.15|7.08|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.15||||14.15|8.92|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.15||||14.15|4.2|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|CIGNA [1260]|CIGNA GWH [126023]|14.15||||14.15|7.78|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14.15||||14.15|9.76|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.15||||14.15|7.08|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.15||||14.15|6.24|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.15||||14.15|4.2|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.15||||14.15|6.24|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.15||||14.15|4.2|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.15||||14.15|4.2|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14.15||||14.15|9.76|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.15||||14.15|4.2|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|Self-pay|Self-pay|14.15||||14.15|4.95|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.15||||14.15|4.2|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.15||||14.15|4.2|9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.15||||14.15||9.76|4.2
10758|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TUBE ENDOTRACHEAL NASAL/ORAL CUFFED 9.0MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.15||||14.15||9.76|4.2
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|AARP [1000]|AARP [100000]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|AETNA [1015]|AETNA [101529]|247.53||||247.53|109.16|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|247.53||||247.53|73.39|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|BCBS [1155]|BCBS UTHCT [115568]|247.53||||247.53|116.34|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|247.53||||247.53|123.77|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|247.53||||247.53|123.77|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|247.53||||247.53|155.94|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|247.53||||247.53|73.39|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|CIGNA [1260]|CIGNA GWH [126023]|247.53||||247.53|136.14|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|GROUP PENSION ADMIN [1450]|GPA [145000]|247.53||||247.53|170.8|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|247.53||||247.53|123.77|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|247.53||||247.53|109.16|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|247.53||||247.53|73.39|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|247.53||||247.53|109.16|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|247.53||||247.53|73.39|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|247.53||||247.53|73.39|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|PHCS [1780]|PHCS MULTIPLAN [178000]|247.53||||247.53|170.8|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|247.53||||247.53|73.39|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|Self-pay|Self-pay|247.53||||247.53|86.64|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|247.53||||247.53|73.39|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|247.53||||247.53|73.39|170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|247.53||||247.53||170.8|73.39
10760|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #2|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|AARP [1000]|AARP [100000]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|AETNA [1015]|AETNA [101529]|247.53||||247.53|109.16|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|247.53||||247.53|73.39|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|BCBS [1155]|BCBS UTHCT [115568]|247.53||||247.53|116.34|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|247.53||||247.53|123.77|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|247.53||||247.53|123.77|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|247.53||||247.53|155.94|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|247.53||||247.53|73.39|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|CIGNA [1260]|CIGNA GWH [126023]|247.53||||247.53|136.14|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|247.53||||247.53|170.8|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|247.53||||247.53|123.77|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|247.53||||247.53|109.16|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|247.53||||247.53|73.39|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|247.53||||247.53|109.16|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|247.53||||247.53|73.39|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|247.53||||247.53|73.39|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|247.53||||247.53|170.8|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|247.53||||247.53|73.39|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|Self-pay|Self-pay|247.53||||247.53|86.64|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|247.53||||247.53|73.39|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|247.53||||247.53|73.39|170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|247.53||||247.53||170.8|73.39
10761|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|AARP [1000]|AARP [100000]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|AETNA [1015]|AETNA [101529]|247.53||||247.53|109.16|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|247.53||||247.53|73.39|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|BCBS [1155]|BCBS UTHCT [115568]|247.53||||247.53|116.34|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|247.53||||247.53|123.77|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|247.53||||247.53|123.77|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|247.53||||247.53|155.94|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|247.53||||247.53|73.39|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|CIGNA [1260]|CIGNA GWH [126023]|247.53||||247.53|136.14|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|GROUP PENSION ADMIN [1450]|GPA [145000]|247.53||||247.53|170.8|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|247.53||||247.53|123.77|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|247.53||||247.53|109.16|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|247.53||||247.53|73.39|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|247.53||||247.53|109.16|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|247.53||||247.53|73.39|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|247.53||||247.53|73.39|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|PHCS [1780]|PHCS MULTIPLAN [178000]|247.53||||247.53|170.8|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|247.53||||247.53|73.39|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|Self-pay|Self-pay|247.53||||247.53|86.64|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|247.53||||247.53|73.39|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|247.53||||247.53|73.39|170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|247.53||||247.53||170.8|73.39
10762|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY CUBE SIZE #4|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|AARP [1000]|AARP [100000]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|AETNA [1015]|AETNA [101529]|247.53||||247.53|109.16|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|247.53||||247.53|73.39|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|BCBS [1155]|BCBS UTHCT [115568]|247.53||||247.53|116.34|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|247.53||||247.53|123.77|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|247.53||||247.53|123.77|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|247.53||||247.53|155.94|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|247.53||||247.53|73.39|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|CIGNA [1260]|CIGNA GWH [126023]|247.53||||247.53|136.14|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|GROUP PENSION ADMIN [1450]|GPA [145000]|247.53||||247.53|170.8|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|247.53||||247.53|123.77|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|247.53||||247.53|109.16|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|247.53||||247.53|73.39|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|247.53||||247.53|109.16|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|247.53||||247.53|73.39|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|247.53||||247.53|73.39|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|PHCS [1780]|PHCS MULTIPLAN [178000]|247.53||||247.53|170.8|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|247.53||||247.53|73.39|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|Self-pay|Self-pay|247.53||||247.53|86.64|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|247.53||||247.53|73.39|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|247.53||||247.53|73.39|170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|247.53||||247.53||170.8|73.39
10763|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#2|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|AARP [1000]|AARP [100000]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|AETNA [1015]|AETNA [101529]|247.53||||247.53|109.16|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|247.53||||247.53|73.39|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|BCBS [1155]|BCBS UTHCT [115568]|247.53||||247.53|116.34|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|247.53||||247.53|123.77|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|247.53||||247.53|123.77|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|247.53||||247.53|155.94|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|247.53||||247.53|73.39|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|CIGNA [1260]|CIGNA GWH [126023]|247.53||||247.53|136.14|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|247.53||||247.53|170.8|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|247.53||||247.53|123.77|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|247.53||||247.53|109.16|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|247.53||||247.53|73.39|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|247.53||||247.53|109.16|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|247.53||||247.53|73.39|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|247.53||||247.53|73.39|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|247.53||||247.53|170.8|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|247.53||||247.53|73.39|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|Self-pay|Self-pay|247.53||||247.53|86.64|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|247.53||||247.53|73.39|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|247.53||||247.53|73.39|170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|247.53||||247.53||170.8|73.39
10764|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|AARP [1000]|AARP [100000]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|AETNA [1015]|AETNA [101529]|247.53||||247.53|109.16|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|247.53||||247.53|73.39|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|BCBS [1155]|BCBS UTHCT [115568]|247.53||||247.53|116.34|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|247.53||||247.53|123.77|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|247.53||||247.53|123.77|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|247.53||||247.53|155.94|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|247.53||||247.53|73.39|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|CIGNA [1260]|CIGNA GWH [126023]|247.53||||247.53|136.14|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|GROUP PENSION ADMIN [1450]|GPA [145000]|247.53||||247.53|170.8|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|247.53||||247.53|123.77|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|247.53||||247.53|109.16|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|247.53||||247.53|73.39|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|247.53||||247.53|109.16|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|247.53||||247.53|73.39|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|247.53||||247.53|73.39|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|PHCS [1780]|PHCS MULTIPLAN [178000]|247.53||||247.53|170.8|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|247.53||||247.53|73.39|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|Self-pay|Self-pay|247.53||||247.53|86.64|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|247.53||||247.53|73.39|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|247.53||||247.53|73.39|170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|247.53||||247.53||170.8|73.39
10765|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PESSARY RING W/SUPPORT SIZE#4|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|247.53||||247.53||170.8|73.39
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|AARP [1000]|AARP [100000]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|AETNA [1015]|AETNA [101529]|375.1||||375.1|165.42|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|375.1||||375.1|111.22|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|BCBS [1155]|BCBS UTHCT [115568]|375.1||||375.1|176.3|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|375.1||||375.1|187.55|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|375.1||||375.1|187.55|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|375.1||||375.1|236.31|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|375.1||||375.1|111.22|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|CIGNA [1260]|CIGNA GWH [126023]|375.1||||375.1|206.31|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|GROUP PENSION ADMIN [1450]|GPA [145000]|375.1||||375.1|258.82|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|375.1||||375.1|187.55|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|375.1||||375.1|165.42|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|375.1||||375.1|111.22|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|375.1||||375.1|165.42|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|375.1||||375.1|111.22|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|375.1||||375.1|111.22|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|PHCS [1780]|PHCS MULTIPLAN [178000]|375.1||||375.1|258.82|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|375.1||||375.1|111.22|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|Self-pay|Self-pay|375.1||||375.1|131.28|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|375.1||||375.1|111.22|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|375.1||||375.1|111.22|258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|375.1||||375.1||258.82|111.22
10766|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|"PESSARY, 3 1/2"" W/FOLDING RING SUPPORT"|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|375.1||||375.1||258.82|111.22
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|139.13||||139.13|61.36|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139.13||||139.13|41.25|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|139.13||||139.13|65.39|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139.13||||139.13|69.57|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139.13||||139.13|69.57|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139.13||||139.13|87.65|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139.13||||139.13|41.25|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|139.13||||139.13|76.52|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|139.13||||139.13|96|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|139.13||||139.13|69.57|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139.13||||139.13|61.36|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139.13||||139.13|41.25|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139.13||||139.13|61.36|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139.13||||139.13|41.25|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|139.13||||139.13|41.25|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|139.13||||139.13|96|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139.13||||139.13|41.25|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|Self-pay|Self-pay|139.13||||139.13|48.7|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|139.13||||139.13|41.25|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139.13||||139.13|41.25|96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139.13||||139.13||96|41.25
107668|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|139.13||||139.13|61.36|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139.13||||139.13|41.25|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|139.13||||139.13|65.39|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139.13||||139.13|69.57|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139.13||||139.13|69.57|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139.13||||139.13|87.65|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139.13||||139.13|41.25|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|139.13||||139.13|76.52|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|139.13||||139.13|96|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|139.13||||139.13|69.57|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139.13||||139.13|61.36|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139.13||||139.13|41.25|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139.13||||139.13|61.36|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139.13||||139.13|41.25|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|139.13||||139.13|41.25|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|139.13||||139.13|96|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139.13||||139.13|41.25|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|Self-pay|Self-pay|139.13||||139.13|48.7|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|139.13||||139.13|41.25|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139.13||||139.13|41.25|96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139.13||||139.13||96|41.25
107669|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 80 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139.13||||139.13||96|41.25
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|AARP [1000]|AARP [100000]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|AETNA [1015]|AETNA [101529]|8308.55||||8308.55|3664.07|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8308.55||||8308.55|2463.49|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|BCBS [1155]|BCBS UTHCT [115568]|8308.55||||8308.55|3905.02|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8308.55||||8308.55|4154.28|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8308.55||||8308.55|4154.28|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8308.55||||8308.55|5234.39|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8308.55||||8308.55|2463.49|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|CIGNA [1260]|CIGNA GWH [126023]|8308.55||||8308.55|4569.7|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8308.55||||8308.55|5732.9|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8308.55||||8308.55|4154.28|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8308.55||||8308.55|3664.07|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8308.55||||8308.55|2463.49|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8308.55||||8308.55|3664.07|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8308.55||||8308.55|2463.49|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8308.55||||8308.55|2463.49|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8308.55||||8308.55|5732.9|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8308.55||||8308.55|2463.49|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|Self-pay|Self-pay|8308.55||||8308.55|2907.99|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8308.55||||8308.55|2463.49|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8308.55||||8308.55|2463.49|5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8308.55||||8308.55||5732.9|2463.49
10767|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BRAVO CF CAPSULE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8308.55||||8308.55||5732.9|2463.49
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AARP [1000]|AARP [100000]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA [1015]|AETNA [101529]|656.65||||656.65|479.52|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|656.65||||656.65|194.7|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BCBS UTHCT [115568]|656.65||||656.65|308.63|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|656.65||||656.65|0|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|656.65||||656.65|328.33|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|656.65||||656.65|413.69|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|656.65||||656.65|194.7|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA GWH [126023]|656.65||||656.65|328.33|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|656.65||||656.65|453.09|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|656.65||||656.65|4.19|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|656.65||||656.65|479.52|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|656.65||||656.65|194.7|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|656.65||||656.65|479.52|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|656.65||||656.65|194.7|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|656.65||||656.65|194.7|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|656.65||||656.65|453.09|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|656.65||||656.65|194.7|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|Self-pay|Self-pay|656.65||||656.65|229.83|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|656.65||||656.65|194.7|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|656.65||||656.65|194.7|479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|656.65||||656.65||479.52|4.19
107671|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAROLINE FOSAMIL 600 MG INTRAVENOUS SOLUTION|600 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|656.65||||656.65||479.52|4.19
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|AARP [1000]|AARP [100000]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|AETNA [1015]|AETNA [101529]|149.6||||149.6|65.97|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149.6||||149.6|44.36|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|BCBS [1155]|BCBS UTHCT [115568]|149.6||||149.6|70.31|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149.6||||149.6|74.8|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149.6||||149.6|74.8|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149.6||||149.6|94.25|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149.6||||149.6|44.36|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|CIGNA [1260]|CIGNA GWH [126023]|149.6||||149.6|82.28|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149.6||||149.6|103.22|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|149.6||||149.6|74.8|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149.6||||149.6|65.97|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149.6||||149.6|44.36|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149.6||||149.6|65.97|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149.6||||149.6|44.36|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|149.6||||149.6|44.36|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149.6||||149.6|103.22|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149.6||||149.6|44.36|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|Self-pay|Self-pay|149.6||||149.6|52.36|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|149.6||||149.6|44.36|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149.6||||149.6|44.36|103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149.6||||149.6||103.22|44.36
10768|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PULSE OXIMETER FINGER REUSABLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149.6||||149.6||103.22|44.36
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|AARP [1000]|AARP [100000]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|AETNA [1015]|AETNA [101529]|1203.75||||1203.75|530.85|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1203.75||||1203.75|356.91|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|BCBS [1155]|BCBS UTHCT [115568]|1203.75||||1203.75|565.76|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1203.75||||1203.75|601.88|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1203.75||||1203.75|601.88|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1203.75||||1203.75|758.36|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1203.75||||1203.75|356.91|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|CIGNA [1260]|CIGNA GWH [126023]|1203.75||||1203.75|662.06|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1203.75||||1203.75|830.59|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1203.75||||1203.75|601.88|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1203.75||||1203.75|530.85|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1203.75||||1203.75|356.91|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1203.75||||1203.75|530.85|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1203.75||||1203.75|356.91|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1203.75||||1203.75|356.91|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1203.75||||1203.75|830.59|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1203.75||||1203.75|356.91|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|Self-pay|Self-pay|1203.75||||1203.75|421.31|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1203.75||||1203.75|356.91|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1203.75||||1203.75|356.91|830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1203.75||||1203.75||830.59|356.91
10769|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PROBE COAG BIPOLAR 10FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1203.75||||1203.75||830.59|356.91
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|AARP [1000]|AARP [100000]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|AETNA [1015]|AETNA [101529]|63.2||||63.2|27.87|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.2||||63.2|18.74|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|BCBS [1155]|BCBS UTHCT [115568]|63.2||||63.2|29.7|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63.2||||63.2|31.6|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63.2||||63.2|31.6|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63.2||||63.2|39.82|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63.2||||63.2|18.74|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|CIGNA [1260]|CIGNA GWH [126023]|63.2||||63.2|34.76|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63.2||||63.2|43.61|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63.2||||63.2|31.6|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.2||||63.2|27.87|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63.2||||63.2|18.74|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.2||||63.2|27.87|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63.2||||63.2|18.74|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63.2||||63.2|18.74|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63.2||||63.2|43.61|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63.2||||63.2|18.74|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|Self-pay|Self-pay|63.2||||63.2|22.12|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63.2||||63.2|18.74|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63.2||||63.2|18.74|43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63.2||||63.2||43.61|18.74
10771|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATHETER IC FOLEY 14 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63.2||||63.2||43.61|18.74
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|AARP [1000]|AARP [100000]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|AETNA [1015]|AETNA [101529]|143.09||||143.09|63.1|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|143.09||||143.09|42.43|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|BCBS [1155]|BCBS UTHCT [115568]|143.09||||143.09|67.25|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|143.09||||143.09|71.55|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|143.09||||143.09|71.55|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|143.09||||143.09|90.15|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|143.09||||143.09|42.43|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|CIGNA [1260]|CIGNA GWH [126023]|143.09||||143.09|78.7|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|GROUP PENSION ADMIN [1450]|GPA [145000]|143.09||||143.09|98.73|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|143.09||||143.09|71.55|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|143.09||||143.09|63.1|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|143.09||||143.09|42.43|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|143.09||||143.09|63.1|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|143.09||||143.09|42.43|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|143.09||||143.09|42.43|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|PHCS [1780]|PHCS MULTIPLAN [178000]|143.09||||143.09|98.73|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|143.09||||143.09|42.43|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|Self-pay|Self-pay|143.09||||143.09|50.08|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|143.09||||143.09|42.43|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|143.09||||143.09|42.43|98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|143.09||||143.09||98.73|42.43
10772|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|TRANSDUCER SYSTEM VAMP COMBINATION KIT 10/CS. #EDWARDS #P|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|143.09||||143.09||98.73|42.43
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|AARP [1000]|AARP [100000]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|AETNA [1015]|AETNA [101529]|1||||1|0.44|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1||||1|0.3|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|BCBS [1155]|BCBS UTHCT [115568]|1||||1|0.47|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1||||1|0.5|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1||||1|0.5|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1||||1|0.63|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1||||1|0.3|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|CIGNA [1260]|CIGNA GWH [126023]|1||||1|0.55|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1||||1|0.69|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1||||1|0.5|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1||||1|0.44|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1||||1|0.3|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1||||1|0.44|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1||||1|0.3|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1||||1|0.3|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1||||1|0.69|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1||||1|0.3|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|Self-pay|Self-pay|1||||1|0.35|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1||||1|0.3|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1||||1|0.3|0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1||||1||0.69|0.3
10773|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|AIRWAY CHILD 60 MM SIZE 2|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1||||1||0.69|0.3
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AARP [1000]|AARP [100000]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AETNA [1015]|AETNA [101529]|0.77||||0.77|0.1|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.77||||0.77|0.23|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.77||||0.77|0.36|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.77||||0.77|0|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.77||||0.77|0.39|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.77||||0.77|0.49|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.77||||0.77|0.23|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.77||||0.77|0.42|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.77||||0.77|0.53|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.77||||0.77|0.03|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.77||||0.77|0.1|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.77||||0.77|0.23|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.77||||0.77|0.1|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.77||||0.77|0.23|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.77||||0.77|0.23|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.77||||0.77|0.53|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.77||||0.77|0.23|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|Self-pay|Self-pay|0.77||||0.77|0.27|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.77||||0.77|0.23|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.77||||0.77|0.23|43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.77||||0.77||43.91|0.03
10778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON HCL 4 MG TABLET|0.5 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.77||||0.77||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|AARP [1000]|AARP [100000]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|AETNA [1015]|AETNA [101529]|63.64||||63.64|28.07|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.64||||63.64|18.87|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|BCBS [1155]|BCBS UTHCT [115568]|63.64||||63.64|29.91|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63.64||||63.64|31.82|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63.64||||63.64|31.82|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63.64||||63.64|40.09|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63.64||||63.64|18.87|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|CIGNA [1260]|CIGNA GWH [126023]|63.64||||63.64|35|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63.64||||63.64|43.91|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63.64||||63.64|31.82|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.64||||63.64|28.07|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63.64||||63.64|18.87|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.64||||63.64|28.07|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63.64||||63.64|18.87|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63.64||||63.64|18.87|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63.64||||63.64|43.91|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63.64||||63.64|18.87|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|Self-pay|Self-pay|63.64||||63.64|22.27|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63.64||||63.64|18.87|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63.64||||63.64|18.87|43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63.64||||63.64||43.91|0.03
10778|SUP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|SUPPORT KNEE NEOPRENE WITH REINFORCED PATELLA SUPPORT 14|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63.64||||63.64||43.91|0.03
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|AARP [1000]|AARP [100000]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|AETNA [1015]|AETNA [101529]|89.28||||89.28|39.37|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89.28||||89.28|26.47|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|BCBS [1155]|BCBS UTHCT [115568]|89.28||||89.28|41.96|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89.28||||89.28|44.64|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89.28||||89.28|44.64|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89.28||||89.28|56.25|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89.28||||89.28|26.47|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|CIGNA [1260]|CIGNA GWH [126023]|89.28||||89.28|49.1|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|89.28||||89.28|61.6|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|89.28||||89.28|44.64|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89.28||||89.28|39.37|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89.28||||89.28|26.47|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89.28||||89.28|39.37|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|89.28||||89.28|26.47|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|89.28||||89.28|26.47|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|89.28||||89.28|61.6|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89.28||||89.28|26.47|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|Self-pay|Self-pay|89.28||||89.28|31.25|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|89.28||||89.28|26.47|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89.28||||89.28|26.47|61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89.28||||89.28||61.6|26.47
10780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BALANCED SALT SOLUTION NON-SURGICAL NO.3 EYE WASH|120 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|89.28||||89.28||61.6|26.47
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|AARP [1000]|AARP [100000]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|AETNA [1015]|AETNA [101529]|9.52||||9.52|4.2|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.52||||9.52|2.82|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|BCBS [1155]|BCBS UTHCT [115568]|9.52||||9.52|4.47|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.52||||9.52|4.76|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.52||||9.52|4.76|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.52||||9.52|6|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.52||||9.52|2.82|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|CIGNA [1260]|CIGNA GWH [126023]|9.52||||9.52|5.24|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.52||||9.52|6.57|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.52||||9.52|4.76|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.52||||9.52|4.2|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.52||||9.52|2.82|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.52||||9.52|4.2|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.52||||9.52|2.82|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.52||||9.52|2.82|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.52||||9.52|6.57|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.52||||9.52|2.82|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|Self-pay|Self-pay|9.52||||9.52|3.33|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.52||||9.52|2.82|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.52||||9.52|2.82|459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.52||||9.52||459.2|2.82
10782|ERX|0250 - PHARMACY-GENERAL|SODIUM BORATE-BORIC ACID-SODIUM CHLORIDE-WATER EYE WASH SOLN|118 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.52||||9.52||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|AARP [1000]|AARP [100000]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|AETNA [1015]|AETNA [101529]|665.5||||665.5|293.49|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|665.5||||665.5|197.32|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|BCBS [1155]|BCBS UTHCT [115568]|665.5||||665.5|312.79|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|665.5||||665.5|332.75|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|665.5||||665.5|332.75|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|665.5||||665.5|419.27|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|665.5||||665.5|197.32|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|CIGNA [1260]|CIGNA GWH [126023]|665.5||||665.5|366.03|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|GROUP PENSION ADMIN [1450]|GPA [145000]|665.5||||665.5|459.2|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|665.5||||665.5|332.75|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|665.5||||665.5|293.49|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|665.5||||665.5|197.32|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|665.5||||665.5|293.49|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|665.5||||665.5|197.32|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|665.5||||665.5|197.32|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|PHCS [1780]|PHCS MULTIPLAN [178000]|665.5||||665.5|459.2|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|665.5||||665.5|197.32|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|Self-pay|Self-pay|665.5||||665.5|232.92|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|665.5||||665.5|197.32|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|665.5||||665.5|197.32|459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|665.5||||665.5||459.2|2.82
10782|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CATH, DILATION FUSION FS-DBC-7|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|665.5||||665.5||459.2|2.82
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|16.37||||16.37|7.22|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|16.37||||16.37|7.22|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|16.37||||16.37|7.69|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|16.37||||16.37|7.69|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.37||||16.37|8.19|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.37||||16.37|8.19|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.37||||16.37|8.19|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.37||||16.37|8.19|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.37||||16.37|10.31|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.37||||16.37|10.31|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|16.37||||16.37|9|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|16.37||||16.37|9|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.37||||16.37|11.3|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.37||||16.37|11.3|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.37||||16.37|8.19|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.37||||16.37|8.19|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.37||||16.37|7.22|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.37||||16.37|7.22|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.37||||16.37|7.22|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.37||||16.37|7.22|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.37||||16.37|11.3|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.37||||16.37|11.3|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|16.37||||16.37|5.73|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|16.37||||16.37|5.73|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.37||||16.37|4.85|11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.37||||16.37||11.3|4.85
107829|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLYCOPYRROLATE 1 MG/5 ML (0.2 MG/ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.37||||16.37||11.3|4.85
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|AARP [1000]|AARP [100000]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|AETNA [1015]|AETNA [101529]|1177||||1177|519.06|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1177||||1177|348.98|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|BCBS [1155]|BCBS UTHCT [115568]|1177||||1177|553.19|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1177||||1177|588.5|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1177||||1177|588.5|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1177||||1177|741.51|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1177||||1177|348.98|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|CIGNA [1260]|CIGNA GWH [126023]|1177||||1177|647.35|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1177||||1177|812.13|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1177||||1177|588.5|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1177||||1177|519.06|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1177||||1177|348.98|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1177||||1177|519.06|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1177||||1177|348.98|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1177||||1177|348.98|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1177||||1177|812.13|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1177||||1177|348.98|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|Self-pay|Self-pay|1177||||1177|411.95|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1177||||1177|348.98|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1177||||1177|348.98|812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1177||||1177||812.13|348.98
10785|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BALLOON HBD-W-8-9-10|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1177||||1177||812.13|348.98
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|AARP [1000]|AARP [100000]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|AETNA [1015]|AETNA [101529]|1246.55||||1246.55|549.73|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1246.55||||1246.55|369.6|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|BCBS [1155]|BCBS UTHCT [115568]|1246.55||||1246.55|585.88|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1246.55||||1246.55|623.28|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1246.55||||1246.55|623.28|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1246.55||||1246.55|785.33|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1246.55||||1246.55|369.6|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|CIGNA [1260]|CIGNA GWH [126023]|1246.55||||1246.55|685.6|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1246.55||||1246.55|860.12|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1246.55||||1246.55|623.28|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1246.55||||1246.55|549.73|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1246.55||||1246.55|369.6|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1246.55||||1246.55|549.73|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1246.55||||1246.55|369.6|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1246.55||||1246.55|369.6|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1246.55||||1246.55|860.12|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1246.55||||1246.55|369.6|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|Self-pay|Self-pay|1246.55||||1246.55|436.29|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1246.55||||1246.55|369.6|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1246.55||||1246.55|369.6|860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1246.55||||1246.55||860.12|369.6
10786|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 6MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|AARP [1000]|AARP [100000]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|AETNA [1015]|AETNA [101529]|1246.55||||1246.55|549.73|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1246.55||||1246.55|369.6|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|BCBS [1155]|BCBS UTHCT [115568]|1246.55||||1246.55|585.88|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1246.55||||1246.55|623.28|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1246.55||||1246.55|623.28|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1246.55||||1246.55|785.33|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1246.55||||1246.55|369.6|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|CIGNA [1260]|CIGNA GWH [126023]|1246.55||||1246.55|685.6|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1246.55||||1246.55|860.12|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1246.55||||1246.55|623.28|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1246.55||||1246.55|549.73|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1246.55||||1246.55|369.6|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1246.55||||1246.55|549.73|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1246.55||||1246.55|369.6|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1246.55||||1246.55|369.6|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1246.55||||1246.55|860.12|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1246.55||||1246.55|369.6|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|Self-pay|Self-pay|1246.55||||1246.55|436.29|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1246.55||||1246.55|369.6|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1246.55||||1246.55|369.6|860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1246.55||||1246.55||860.12|369.6
10787|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 10MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1246.55||||1246.55||860.12|369.6
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|AARP [1000]|AARP [100000]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|AETNA [1015]|AETNA [101529]|1118.15||||1118.15|493.1|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1118.15||||1118.15|331.53|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|BCBS [1155]|BCBS UTHCT [115568]|1118.15||||1118.15|525.53|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1118.15||||1118.15|559.08|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1118.15||||1118.15|559.08|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1118.15||||1118.15|704.43|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1118.15||||1118.15|331.53|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|CIGNA [1260]|CIGNA GWH [126023]|1118.15||||1118.15|614.98|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1118.15||||1118.15|771.52|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1118.15||||1118.15|559.08|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1118.15||||1118.15|493.1|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1118.15||||1118.15|331.53|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1118.15||||1118.15|493.1|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1118.15||||1118.15|331.53|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1118.15||||1118.15|331.53|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1118.15||||1118.15|771.52|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1118.15||||1118.15|331.53|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|Self-pay|Self-pay|1118.15||||1118.15|391.35|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1118.15||||1118.15|331.53|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1118.15||||1118.15|331.53|771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1118.15||||1118.15||771.52|331.53
10788|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HUIBREGTSE NEEDLE KNIFE PAPILLOTOME|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1118.15||||1118.15||771.52|331.53
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|AARP [1000]|AARP [100000]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|AETNA [1015]|AETNA [101529]|334.5||||334.5|147.51|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|334.5||||334.5|99.18|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|BCBS [1155]|BCBS UTHCT [115568]|334.5||||334.5|157.22|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|334.5||||334.5|167.25|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|334.5||||334.5|167.25|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|334.5||||334.5|210.74|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|334.5||||334.5|99.18|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|CIGNA [1260]|CIGNA GWH [126023]|334.5||||334.5|183.98|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|334.5||||334.5|230.81|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|334.5||||334.5|157.22|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|334.5||||334.5|147.51|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|334.5||||334.5|99.18|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|334.5||||334.5|147.51|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|334.5||||334.5|99.18|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|334.5||||334.5|99.18|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|334.5||||334.5|230.81|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|334.5||||334.5|99.18|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|Self-pay|Self-pay|334.5||||334.5|117.07|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|334.5||||334.5|99.18|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|334.5||||334.5|99.18|230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|334.5||||334.5||230.81|99.18
10789|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COMPASS BILIARY STENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|334.5||||334.5||230.81|99.18
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|0.09||||0.09|0.04|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.09||||0.09|0.03|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.09||||0.09|0.04|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.09||||0.09|0.05|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.09||||0.09|0.05|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.09||||0.09|0.06|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.09||||0.09|0.03|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.09||||0.09|0.05|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.09||||0.09|0.06|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.09||||0.09|0.05|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.09||||0.09|0.04|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.09||||0.09|0.03|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.09||||0.09|0.04|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.09||||0.09|0.03|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.09||||0.09|0.03|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.09||||0.09|0.06|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.09||||0.09|0.03|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|0.09||||0.09|0.03|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.09||||0.09|0.03|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.09||||0.09|0.03|0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.09||||0.09||0.06|0.03
1079|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISACODYL 5 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.09||||0.09||0.06|0.03
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|AARP [1000]|AARP [100000]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|AETNA [1015]|AETNA [101529]|363||||363|160.08|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|363||||363|107.63|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|BCBS [1155]|BCBS UTHCT [115568]|363||||363|170.61|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|363||||363|181.5|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|363||||363|181.5|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|363||||363|228.69|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|363||||363|107.63|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|CIGNA [1260]|CIGNA GWH [126023]|363||||363|199.65|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|GROUP PENSION ADMIN [1450]|GPA [145000]|363||||363|250.47|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|363||||363|170.61|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|363||||363|160.08|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|363||||363|107.63|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|363||||363|160.08|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|363||||363|107.63|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|363||||363|107.63|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|PHCS [1780]|PHCS MULTIPLAN [178000]|363||||363|250.47|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|363||||363|107.63|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|Self-pay|Self-pay|363||||363|127.05|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|363||||363|107.63|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|363||||363|107.63|250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|363||||363||250.47|107.63
10790|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|DOUBLE LOOP BILIARY STENT 7X5|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|363||||363||250.47|107.63
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|AARP [1000]|AARP [100000]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|AETNA [1015]|AETNA [101529]|1118.15||||1118.15|493.1|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1118.15||||1118.15|331.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|BCBS [1155]|BCBS UTHCT [115568]|1118.15||||1118.15|525.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1118.15||||1118.15|559.08|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1118.15||||1118.15|559.08|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1118.15||||1118.15|704.43|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1118.15||||1118.15|331.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|CIGNA [1260]|CIGNA GWH [126023]|1118.15||||1118.15|559.08|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1118.15||||1118.15|771.52|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1118.15||||1118.15|525.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1118.15||||1118.15|493.1|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1118.15||||1118.15|331.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1118.15||||1118.15|493.1|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1118.15||||1118.15|331.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1118.15||||1118.15|331.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1118.15||||1118.15|771.52|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1118.15||||1118.15|331.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|Self-pay|Self-pay|1118.15||||1118.15|391.35|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1118.15||||1118.15|331.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1118.15||||1118.15|331.53|771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1118.15||||1118.15||771.52|331.53
10792|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 9X7|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1118.15||||1118.15||771.52|331.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|AARP [1000]|AARP [100000]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|AETNA [1015]|AETNA [101529]|963||||963|424.68|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|963||||963|285.53|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|BCBS [1155]|BCBS UTHCT [115568]|963||||963|452.61|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|963||||963|481.5|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|963||||963|481.5|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|963||||963|606.69|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|963||||963|285.53|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|CIGNA [1260]|CIGNA GWH [126023]|963||||963|529.65|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|GROUP PENSION ADMIN [1450]|GPA [145000]|963||||963|664.47|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|963||||963|481.5|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|963||||963|424.68|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|963||||963|285.53|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|963||||963|424.68|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|963||||963|285.53|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|963||||963|285.53|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|PHCS [1780]|PHCS MULTIPLAN [178000]|963||||963|664.47|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|963||||963|285.53|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|Self-pay|Self-pay|963||||963|337.05|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|963||||963|285.53|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|963||||963|285.53|664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|963||||963||664.47|285.53
10793|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HERCULES-3 STAGE BALLOON ESOPHAGEAL 8-9-10|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|963||||963||664.47|285.53
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|AARP [1000]|AARP [100000]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|AETNA [1015]|AETNA [101529]|1107.45||||1107.45|488.39|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1107.45||||1107.45|328.36|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|BCBS [1155]|BCBS UTHCT [115568]|1107.45||||1107.45|520.5|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1107.45||||1107.45|553.73|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1107.45||||1107.45|553.73|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1107.45||||1107.45|697.69|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1107.45||||1107.45|328.36|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|CIGNA [1260]|CIGNA GWH [126023]|1107.45||||1107.45|609.1|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1107.45||||1107.45|764.14|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1107.45||||1107.45|553.73|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1107.45||||1107.45|488.39|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1107.45||||1107.45|328.36|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1107.45||||1107.45|488.39|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1107.45||||1107.45|328.36|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1107.45||||1107.45|328.36|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1107.45||||1107.45|764.14|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1107.45||||1107.45|328.36|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|Self-pay|Self-pay|1107.45||||1107.45|387.61|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1107.45||||1107.45|328.36|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1107.45||||1107.45|328.36|764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1107.45||||1107.45||764.14|328.36
10794|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|APC PROBE STRAIGHT FIRE FLEXIBLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1107.45||||1107.45||764.14|328.36
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|AARP [1000]|AARP [100000]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|AETNA [1015]|AETNA [101529]|780.45||||780.45|344.18|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780.45||||780.45|231.4|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|BCBS [1155]|BCBS UTHCT [115568]|780.45||||780.45|366.81|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780.45||||780.45|390.23|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780.45||||780.45|390.23|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780.45||||780.45|491.68|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780.45||||780.45|231.4|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|CIGNA [1260]|CIGNA GWH [126023]|780.45||||780.45|429.25|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780.45||||780.45|538.51|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780.45||||780.45|366.81|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780.45||||780.45|344.18|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780.45||||780.45|231.4|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780.45||||780.45|344.18|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780.45||||780.45|231.4|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780.45||||780.45|231.4|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780.45||||780.45|538.51|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780.45||||780.45|231.4|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|Self-pay|Self-pay|780.45||||780.45|273.16|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780.45||||780.45|231.4|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780.45||||780.45|231.4|538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780.45||||780.45||538.51|231.4
10795|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X5|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780.45||||780.45||538.51|231.4
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|AARP [1000]|AARP [100000]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|AETNA [1015]|AETNA [101529]|529.38||||529.38|233.45|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|529.38||||529.38|156.96|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|BCBS [1155]|BCBS UTHCT [115568]|529.38||||529.38|248.81|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|529.38||||529.38|264.69|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|529.38||||529.38|264.69|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|529.38||||529.38|333.51|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|529.38||||529.38|156.96|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|CIGNA [1260]|CIGNA GWH [126023]|529.38||||529.38|291.16|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|GROUP PENSION ADMIN [1450]|GPA [145000]|529.38||||529.38|365.27|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|529.38||||529.38|264.69|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|529.38||||529.38|233.45|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|529.38||||529.38|156.96|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|529.38||||529.38|233.45|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|529.38||||529.38|156.96|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|529.38||||529.38|156.96|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|PHCS [1780]|PHCS MULTIPLAN [178000]|529.38||||529.38|365.27|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|529.38||||529.38|156.96|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|Self-pay|Self-pay|529.38||||529.38|185.29|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|529.38||||529.38|156.96|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|529.38||||529.38|156.96|365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|529.38||||529.38||365.27|156.96
10796|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION OMNI ERCP CATHETER 7FR 200 CM .035|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|529.38||||529.38||365.27|156.96
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|AARP [1000]|AARP [100000]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|AETNA [1015]|AETNA [101529]|1150.25||||1150.25|507.26|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1150.25||||1150.25|341.05|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|BCBS [1155]|BCBS UTHCT [115568]|1150.25||||1150.25|540.62|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1150.25||||1150.25|575.13|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1150.25||||1150.25|575.13|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1150.25||||1150.25|724.66|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1150.25||||1150.25|341.05|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|CIGNA [1260]|CIGNA GWH [126023]|1150.25||||1150.25|632.64|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1150.25||||1150.25|793.67|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1150.25||||1150.25|575.13|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1150.25||||1150.25|507.26|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1150.25||||1150.25|341.05|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1150.25||||1150.25|507.26|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1150.25||||1150.25|341.05|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1150.25||||1150.25|341.05|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1150.25||||1150.25|793.67|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1150.25||||1150.25|341.05|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|Self-pay|Self-pay|1150.25||||1150.25|402.59|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1150.25||||1150.25|341.05|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1150.25||||1150.25|341.05|793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1150.25||||1150.25||793.67|341.05
10800|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|6 SHOOTER MULTI BAND LIGATOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1150.25||||1150.25||793.67|341.05
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|AARP [1000]|AARP [100000]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|AETNA [1015]|AETNA [101529]|1072.94||||1072.94|473.17|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1072.94||||1072.94|318.13|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|BCBS [1155]|BCBS UTHCT [115568]|1072.94||||1072.94|504.28|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1072.94||||1072.94|536.47|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1072.94||||1072.94|536.47|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1072.94||||1072.94|675.95|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1072.94||||1072.94|318.13|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|CIGNA [1260]|CIGNA GWH [126023]|1072.94||||1072.94|536.47|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1072.94||||1072.94|740.33|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1072.94||||1072.94|504.28|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1072.94||||1072.94|473.17|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1072.94||||1072.94|318.13|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1072.94||||1072.94|473.17|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1072.94||||1072.94|318.13|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1072.94||||1072.94|318.13|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1072.94||||1072.94|740.33|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1072.94||||1072.94|318.13|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|Self-pay|Self-pay|1072.94||||1072.94|375.53|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1072.94||||1072.94|318.13|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1072.94||||1072.94|318.13|740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1072.94||||1072.94||740.33|318.13
10801|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|ADVANIX BILLIARY 10FR X7CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1072.94||||1072.94||740.33|318.13
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|AARP [1000]|AARP [100000]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|AETNA [1015]|AETNA [101529]|8827.5||||8827.5|3892.93|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|BCBS [1155]|BCBS UTHCT [115568]|8827.5||||8827.5|4148.93|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8827.5||||8827.5|4413.75|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8827.5||||8827.5|4413.75|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8827.5||||8827.5|5561.33|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|CIGNA [1260]|CIGNA GWH [126023]|8827.5||||8827.5|4855.13|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8827.5||||8827.5|4413.75|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8827.5||||8827.5|2617.35|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|Self-pay|Self-pay|8827.5||||8827.5|3089.62|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8827.5||||8827.5||6090.98|2617.35
10802|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 18MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8827.5||||8827.5||6090.98|2617.35
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|146.94||||146.94|110.4|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146.94||||146.94|43.57|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|146.94||||146.94|69.06|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146.94||||146.94|0|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146.94||||146.94|73.47|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146.94||||146.94|92.57|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146.94||||146.94|43.57|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|146.94||||146.94|80.82|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|146.94||||146.94|101.39|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|146.94||||146.94|73.47|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146.94||||146.94|110.4|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146.94||||146.94|43.57|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146.94||||146.94|110.4|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146.94||||146.94|43.57|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|146.94||||146.94|43.57|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|146.94||||146.94|101.39|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146.94||||146.94|43.57|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|146.94||||146.94|51.43|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|146.94||||146.94|43.57|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146.94||||146.94|43.57|110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146.94||||146.94||110.4|43.57
108021|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146.94||||146.94||110.4|43.57
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AARP [1000]|AARP [100000]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AETNA [1015]|AETNA [101529]|168.4||||168.4|52.92|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|168.4||||168.4|49.93|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS [1155]|BCBS UTHCT [115568]|168.4||||168.4|79.15|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|168.4||||168.4|0|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|168.4||||168.4|84.2|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|168.4||||168.4|106.09|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|168.4||||168.4|49.93|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|CIGNA [1260]|CIGNA GWH [126023]|168.4||||168.4|92.62|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|168.4||||168.4|116.2|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|168.4||||168.4|2.14|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|168.4||||168.4|52.92|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|168.4||||168.4|49.93|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|168.4||||168.4|52.92|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|168.4||||168.4|49.93|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|168.4||||168.4|49.93|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|168.4||||168.4|116.2|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|168.4||||168.4|49.93|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|Self-pay|Self-pay|168.4||||168.4|58.94|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|168.4||||168.4|49.93|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|168.4||||168.4|49.93|116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|168.4||||168.4||116.2|2.14
108028|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|168.4||||168.4||116.2|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AARP [1000]|AARP [100000]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AETNA [1015]|AETNA [101529]|181.35||||181.35|70.56|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181.35||||181.35|53.77|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS [1155]|BCBS UTHCT [115568]|181.35||||181.35|85.23|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181.35||||181.35|0|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181.35||||181.35|90.68|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181.35||||181.35|114.25|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181.35||||181.35|53.77|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|CIGNA [1260]|CIGNA GWH [126023]|181.35||||181.35|99.74|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|181.35||||181.35|125.13|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|181.35||||181.35|2.14|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181.35||||181.35|70.56|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181.35||||181.35|53.77|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181.35||||181.35|70.56|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181.35||||181.35|53.77|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|181.35||||181.35|53.77|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|181.35||||181.35|125.13|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181.35||||181.35|53.77|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|Self-pay|Self-pay|181.35||||181.35|63.47|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|181.35||||181.35|53.77|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181.35||||181.35|53.77|125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181.35||||181.35||125.13|2.14
108029|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FONDAPARINUX 10 MG/0.8 ML SUBCUTANEOUS SOLUTION SYRINGE|0.8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181.35||||181.35||125.13|2.14
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|AARP [1000]|AARP [100000]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|AETNA [1015]|AETNA [101529]|8827.5||||8827.5|3892.93|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|BCBS [1155]|BCBS UTHCT [115568]|8827.5||||8827.5|4148.93|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8827.5||||8827.5|4413.75|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8827.5||||8827.5|4413.75|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8827.5||||8827.5|5561.33|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|CIGNA [1260]|CIGNA GWH [126023]|8827.5||||8827.5|4855.13|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8827.5||||8827.5|4413.75|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8827.5||||8827.5|2617.35|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|Self-pay|Self-pay|8827.5||||8827.5|3089.62|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8827.5||||8827.5||6090.98|2617.35
10803|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 22MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|AARP [1000]|AARP [100000]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|AETNA [1015]|AETNA [101529]|8827.5||||8827.5|3892.93|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|BCBS [1155]|BCBS UTHCT [115568]|8827.5||||8827.5|4148.93|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8827.5||||8827.5|4413.75|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8827.5||||8827.5|4413.75|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8827.5||||8827.5|5561.33|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|CIGNA [1260]|CIGNA GWH [126023]|8827.5||||8827.5|4855.13|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8827.5||||8827.5|4413.75|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8827.5||||8827.5|2617.35|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|Self-pay|Self-pay|8827.5||||8827.5|3089.62|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8827.5||||8827.5||6090.98|2617.35
10804|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 25MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8827.5||||8827.5||6090.98|2617.35
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AARP [1000]|AARP [100000]|533.69||||533.69|180.12|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|533.69||||533.69|181.18|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|533.69||||533.69|432.86|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|533.69||||533.69|158.24|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|533.69||||533.69|179.39|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|533.69||||533.69|179.39|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|533.69||||533.69|250.83|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|533.69||||533.69|0|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|533.69||||533.69|266.85|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|533.69||||533.69|336.22|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|533.69||||533.69|158.24|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|533.69||||533.69|179.39|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|533.69||||533.69|266.85|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|533.69||||533.69|368.25|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|533.69||||533.69|18.88|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|533.69||||533.69|179.39|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|533.69||||533.69|432.86|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|533.69||||533.69|158.24|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|533.69||||533.69|179.39|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|533.69||||533.69|432.86|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|533.69||||533.69|158.24|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|533.69||||533.69|158.24|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|533.69||||533.69|368.25|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|533.69||||533.69|158.24|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|Self-pay|Self-pay|533.69||||533.69|186.79|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|533.69||||533.69|158.24|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|533.69||||533.69|158.24|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|533.69||||533.69|180.12|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|533.69||||533.69|179.39|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|533.69||||533.69|179.39|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|533.69||||533.69|180.12|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|533.69||||533.69|179.39|432.86|18.88
108049|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 1,200,000 UNIT/2 ML INTRAMUSCULAR SYRINGE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|533.69||||533.69|358.78|432.86|18.88
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|AARP [1000]|AARP [100000]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|AETNA [1015]|AETNA [101529]|8827.5||||8827.5|3892.93|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|BCBS [1155]|BCBS UTHCT [115568]|8827.5||||8827.5|4148.93|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8827.5||||8827.5|4413.75|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8827.5||||8827.5|4413.75|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8827.5||||8827.5|5561.33|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|CIGNA [1260]|CIGNA GWH [126023]|8827.5||||8827.5|4855.13|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8827.5||||8827.5|4413.75|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8827.5||||8827.5|2617.35|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|Self-pay|Self-pay|8827.5||||8827.5|3089.62|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8827.5||||8827.5||6090.98|2617.35
10805|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 28MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8827.5||||8827.5||6090.98|2617.35
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|AARP [1000]|AARP [100000]|546.81||||546.81|180.12|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|546.81||||546.81|181.18|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|546.81||||546.81|432.86|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|546.81||||546.81|162.13|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|546.81||||546.81|179.39|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|546.81||||546.81|179.39|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|546.81||||546.81|257|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|546.81||||546.81|0|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|546.81||||546.81|273.41|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|546.81||||546.81|344.49|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|546.81||||546.81|162.13|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|546.81||||546.81|179.39|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|546.81||||546.81|273.41|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|546.81||||546.81|377.3|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|546.81||||546.81|18.88|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|546.81||||546.81|179.39|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|546.81||||546.81|432.86|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|546.81||||546.81|162.13|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|546.81||||546.81|179.39|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|546.81||||546.81|432.86|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|546.81||||546.81|162.13|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|546.81||||546.81|162.13|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|546.81||||546.81|377.3|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|546.81||||546.81|162.13|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|Self-pay|Self-pay|546.81||||546.81|191.38|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|546.81||||546.81|162.13|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|546.81||||546.81|162.13|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|546.81||||546.81|180.12|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|546.81||||546.81|179.39|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|546.81||||546.81|179.39|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|546.81||||546.81|180.12|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|546.81||||546.81|179.39|432.86|18.88
108050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE 2,400,000 UNIT/4 ML INTRAMUSCULAR SYRINGE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|546.81||||546.81|358.78|432.86|18.88
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|AARP [1000]|AARP [100000]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|425.43||||425.43|336.38|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|425.43||||425.43|126.14|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|425.43||||425.43|199.95|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|425.43||||425.43|0|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|425.43||||425.43|212.72|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|425.43||||425.43|268.02|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|425.43||||425.43|126.14|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|425.43||||425.43|233.99|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|425.43||||425.43|293.55|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|425.43||||425.43|15.01|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|425.43||||425.43|336.38|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|425.43||||425.43|126.14|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|425.43||||425.43|336.38|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|425.43||||425.43|126.14|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|425.43||||425.43|126.14|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|425.43||||425.43|293.55|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|425.43||||425.43|126.14|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|Self-pay|Self-pay|425.43||||425.43|148.9|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|425.43||||425.43|126.14|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|425.43||||425.43|126.14|336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|425.43||||425.43||336.38|15.01
108051|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G BENZATHINE AND PROCAINE 1,200,000 UNIT/2 ML IM SYRINGE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|425.43||||425.43||336.38|15.01
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|4211.94||||4211.94|1320.9|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4211.94||||4211.94|1316.83|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|4211.94||||4211.94|2947.2|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4211.94||||4211.94|1248.84|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4211.94||||4211.94|1303.79|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4211.94||||4211.94|1303.79|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|4211.94||||4211.94|1979.61|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4211.94||||4211.94|0|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4211.94||||4211.94|2105.97|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4211.94||||4211.94|2653.52|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4211.94||||4211.94|1248.84|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4211.94||||4211.94|1303.79|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|4211.94||||4211.94|2105.97|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4211.94||||4211.94|2906.24|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4211.94||||4211.94|155.21|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4211.94||||4211.94|1303.79|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4211.94||||4211.94|2947.2|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4211.94||||4211.94|1248.84|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4211.94||||4211.94|1303.79|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4211.94||||4211.94|2947.2|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4211.94||||4211.94|1248.84|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4211.94||||4211.94|1248.84|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4211.94||||4211.94|2906.24|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4211.94||||4211.94|1248.84|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|4211.94||||4211.94|1474.18|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4211.94||||4211.94|1248.84|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4211.94||||4211.94|1248.84|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4211.94||||4211.94|1320.9|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4211.94||||4211.94|1303.79|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4211.94||||4211.94|1303.79|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4211.94||||4211.94|1320.9|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4211.94||||4211.94|1303.79|2947.2|155.21
108055|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 100 MG/5 ML (20 MG/ML) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4211.94||||4211.94|2607.58|2947.2|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|16847.76||||16847.76|8423.88|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16847.76||||16847.76|5267.31|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|16847.76||||16847.76|11788.8|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16847.76||||16847.76|4995.36|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16847.76||||16847.76|5215.16|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16847.76||||16847.76|5215.16|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|16847.76||||16847.76|7918.45|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16847.76||||16847.76|0|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16847.76||||16847.76|8423.88|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16847.76||||16847.76|10614.09|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16847.76||||16847.76|4995.36|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16847.76||||16847.76|5215.16|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|16847.76||||16847.76|8423.88|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16847.76||||16847.76|11624.95|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16847.76||||16847.76|155.21|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16847.76||||16847.76|5215.16|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16847.76||||16847.76|11788.8|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16847.76||||16847.76|4995.36|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16847.76||||16847.76|5215.16|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16847.76||||16847.76|11788.8|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16847.76||||16847.76|4995.36|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16847.76||||16847.76|4995.36|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16847.76||||16847.76|11624.95|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16847.76||||16847.76|4995.36|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|16847.76||||16847.76|5896.72|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16847.76||||16847.76|4995.36|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16847.76||||16847.76|4995.36|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16847.76||||16847.76|8423.88|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16847.76||||16847.76|5215.16|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16847.76||||16847.76|5215.16|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16847.76||||16847.76|8423.88|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16847.76||||16847.76|5215.16|11788.8|155.21
108057|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANITUMUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16847.76||||16847.76|10430.32|11788.8|155.21
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|AARP [1000]|AARP [100000]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|AETNA [1015]|AETNA [101529]|8827.5||||8827.5|3892.93|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|BCBS [1155]|BCBS UTHCT [115568]|8827.5||||8827.5|4148.93|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8827.5||||8827.5|4413.75|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8827.5||||8827.5|4413.75|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8827.5||||8827.5|5561.33|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|CIGNA [1260]|CIGNA GWH [126023]|8827.5||||8827.5|4855.13|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8827.5||||8827.5|4413.75|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8827.5||||8827.5|2617.35|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|Self-pay|Self-pay|8827.5||||8827.5|3089.62|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8827.5||||8827.5||6090.98|2617.35
10806|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 RFA BALLON 31MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8827.5||||8827.5||6090.98|2617.35
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|AARP [1000]|AARP [100000]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|AETNA [1015]|AETNA [101529]|2930.68||||2930.68|1292.43|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2930.68||||2930.68|868.95|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|BCBS [1155]|BCBS UTHCT [115568]|2930.68||||2930.68|1377.42|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2930.68||||2930.68|1465.34|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2930.68||||2930.68|1465.34|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2930.68||||2930.68|1846.33|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2930.68||||2930.68|868.95|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|CIGNA [1260]|CIGNA GWH [126023]|2930.68||||2930.68|1465.34|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2930.68||||2930.68|2022.17|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2930.68||||2930.68|1465.34|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2930.68||||2930.68|1292.43|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2930.68||||2930.68|868.95|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2930.68||||2930.68|1292.43|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2930.68||||2930.68|868.95|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2930.68||||2930.68|868.95|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2930.68||||2930.68|2022.17|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2930.68||||2930.68|868.95|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|Self-pay|Self-pay|2930.68||||2930.68|1025.74|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2930.68||||2930.68|868.95|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2930.68||||2930.68|868.95|2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2930.68||||2930.68||2022.17|868.95
108063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOCILIZUMAB 400 MG/20 ML (20 MG/ML) INTRAVENOUS SOLUTION|8.2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2930.68||||2930.68||2022.17|868.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|AARP [1000]|AARP [100000]|9882.06||||9882.06|4941.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9882.06||||9882.06|2844.64|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|AETNA [1015]|AETNA [101529]|9882.06||||9882.06|7526.4|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9882.06||||9882.06|2930.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9882.06||||9882.06|2816.48|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9882.06||||9882.06|2816.48|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|BCBS [1155]|BCBS UTHCT [115568]|9882.06||||9882.06|4644.57|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9882.06||||9882.06|0|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9882.06||||9882.06|4941.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9882.06||||9882.06|6225.7|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9882.06||||9882.06|2930.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9882.06||||9882.06|2816.48|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|CIGNA [1260]|CIGNA GWH [126023]|9882.06||||9882.06|4941.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9882.06||||9882.06|6818.62|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9882.06||||9882.06|93.95|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9882.06||||9882.06|2816.48|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9882.06||||9882.06|7526.4|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9882.06||||9882.06|2930.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9882.06||||9882.06|2816.48|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9882.06||||9882.06|7526.4|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9882.06||||9882.06|2930.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9882.06||||9882.06|2930.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9882.06||||9882.06|6818.62|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9882.06||||9882.06|2930.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|Self-pay|Self-pay|9882.06||||9882.06|3458.72|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9882.06||||9882.06|2930.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9882.06||||9882.06|2930.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9882.06||||9882.06|4941.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9882.06||||9882.06|2816.48|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9882.06||||9882.06|2816.48|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9882.06||||9882.06|4941.03|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9882.06||||9882.06|2816.48|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|16 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9882.06||||9882.06|5632.96|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|2470.52||||2470.52|860.7|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2470.52||||2470.52|711.16|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|2470.52||||2470.52|1881.6|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2470.52||||2470.52|732.51|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2470.52||||2470.52|704.12|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2470.52||||2470.52|704.12|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|2470.52||||2470.52|1161.14|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2470.52||||2470.52|0|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2470.52||||2470.52|1235.26|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2470.52||||2470.52|1556.43|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2470.52||||2470.52|732.51|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2470.52||||2470.52|704.12|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|2470.52||||2470.52|1235.26|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2470.52||||2470.52|1704.66|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2470.52||||2470.52|93.95|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2470.52||||2470.52|704.12|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2470.52||||2470.52|1881.6|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2470.52||||2470.52|732.51|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2470.52||||2470.52|704.12|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2470.52||||2470.52|1881.6|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2470.52||||2470.52|732.51|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2470.52||||2470.52|732.51|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2470.52||||2470.52|1704.66|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2470.52||||2470.52|732.51|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|2470.52||||2470.52|864.68|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2470.52||||2470.52|732.51|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2470.52||||2470.52|732.51|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2470.52||||2470.52|860.7|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2470.52||||2470.52|704.12|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2470.52||||2470.52|704.12|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2470.52||||2470.52|860.7|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2470.52||||2470.52|704.12|7526.4|93.95
108065|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2470.52||||2470.52|1408.24|7526.4|93.95
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|AARP [1000]|AARP [100000]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|AETNA [1015]|AETNA [101529]|4280||||4280|1887.48|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4280||||4280|1269.02|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|BCBS [1155]|BCBS UTHCT [115568]|4280||||4280|2011.6|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4280||||4280|2140|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4280||||4280|2140|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4280||||4280|2696.4|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4280||||4280|1269.02|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|CIGNA [1260]|CIGNA GWH [126023]|4280||||4280|2354|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4280||||4280|2953.2|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4280||||4280|2140|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4280||||4280|1887.48|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4280||||4280|1269.02|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4280||||4280|1887.48|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4280||||4280|1269.02|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4280||||4280|1269.02|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4280||||4280|2953.2|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4280||||4280|1269.02|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|Self-pay|Self-pay|4280||||4280|1498|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4280||||4280|1269.02|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4280||||4280|1269.02|2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4280||||4280||2953.2|1269.02
10807|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 360 SOFT SIZING BALLON 47.5MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4280||||4280||2953.2|1269.02
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|4299.08||||4299.08|1377|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4299.08||||4299.08|1347.44|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|4299.08||||4299.08|3106.08|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4299.08||||4299.08|1274.68|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4299.08||||4299.08|1334.1|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4299.08||||4299.08|1334.1|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|4299.08||||4299.08|2020.57|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4299.08||||4299.08|0|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4299.08||||4299.08|2149.54|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4299.08||||4299.08|2708.42|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4299.08||||4299.08|1274.68|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4299.08||||4299.08|1334.1|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|4299.08||||4299.08|2149.54|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4299.08||||4299.08|2966.37|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4299.08||||4299.08|81.85|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4299.08||||4299.08|1334.1|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4299.08||||4299.08|3106.08|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4299.08||||4299.08|1274.68|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4299.08||||4299.08|1334.1|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4299.08||||4299.08|3106.08|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4299.08||||4299.08|1274.68|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4299.08||||4299.08|1274.68|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4299.08||||4299.08|2966.37|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4299.08||||4299.08|1274.68|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|4299.08||||4299.08|1504.68|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4299.08||||4299.08|1274.68|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4299.08||||4299.08|1274.68|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4299.08||||4299.08|1377|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4299.08||||4299.08|1334.1|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4299.08||||4299.08|1334.1|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4299.08||||4299.08|1377|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4299.08||||4299.08|1334.1|3106.08|81.85
108072|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4299.08||||4299.08|2668.2|3106.08|81.85
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|AARP [1000]|AARP [100000]|1554.13||||1554.13|566.4|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1554.13||||1554.13|471.23|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|AETNA [1015]|AETNA [101529]|1554.13||||1554.13|1059.84|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1554.13||||1554.13|460.8|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1554.13||||1554.13|466.56|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1554.13||||1554.13|466.56|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|BCBS [1155]|BCBS UTHCT [115568]|1554.13||||1554.13|730.44|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1554.13||||1554.13|0|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1554.13||||1554.13|777.07|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1554.13||||1554.13|979.1|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1554.13||||1554.13|460.8|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1554.13||||1554.13|466.56|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|CIGNA [1260]|CIGNA GWH [126023]|1554.13||||1554.13|777.07|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1554.13||||1554.13|1072.35|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1554.13||||1554.13|1.18|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1554.13||||1554.13|466.56|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1554.13||||1554.13|1059.84|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1554.13||||1554.13|460.8|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1554.13||||1554.13|466.56|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1554.13||||1554.13|1059.84|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1554.13||||1554.13|460.8|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1554.13||||1554.13|460.8|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1554.13||||1554.13|1072.35|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1554.13||||1554.13|460.8|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|Self-pay|Self-pay|1554.13||||1554.13|543.95|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1554.13||||1554.13|460.8|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1554.13||||1554.13|460.8|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1554.13||||1554.13|566.4|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1554.13||||1554.13|466.56|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1554.13||||1554.13|466.56|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1554.13||||1554.13|566.4|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1554.13||||1554.13|466.56|1072.35|1.18
108074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 480 MCG/1.6 ML INJECTION SOLUTION|1.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1554.13||||1554.13|933.12|1072.35|1.18
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|AARP [1000]|AARP [100000]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|AETNA [1015]|AETNA [101529]|13910||||13910|6134.31|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13910||||13910|4124.32|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|BCBS [1155]|BCBS UTHCT [115568]|13910||||13910|6537.7|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13910||||13910|6955|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13910||||13910|6955|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13910||||13910|8763.3|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13910||||13910|4124.32|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|CIGNA [1260]|CIGNA GWH [126023]|13910||||13910|7650.5|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13910||||13910|9597.9|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13910||||13910|6955|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13910||||13910|6134.31|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13910||||13910|4124.32|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13910||||13910|6134.31|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13910||||13910|4124.32|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|13910||||13910|4124.32|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13910||||13910|9597.9|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13910||||13910|4124.32|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|Self-pay|Self-pay|13910||||13910|4868.5|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13910||||13910|4124.32|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13910||||13910|4124.32|9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13910||||13910||9597.9|4124.32
10808|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX 90RFA FOCAL 20MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13910||||13910||9597.9|4124.32
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|AARP [1000]|AARP [100000]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|AETNA [1015]|AETNA [101529]|8672.35||||8672.35|3824.51|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|BCBS [1155]|BCBS UTHCT [115568]|8672.35||||8672.35|4076|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8672.35||||8672.35|4336.18|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8672.35||||8672.35|4336.18|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8672.35||||8672.35|5463.58|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|CIGNA [1260]|CIGNA GWH [126023]|8672.35||||8672.35|4769.79|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8672.35||||8672.35|5983.92|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8672.35||||8672.35|4336.18|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8672.35||||8672.35|3824.51|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8672.35||||8672.35|3824.51|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8672.35||||8672.35|2571.35|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8672.35||||8672.35|5983.92|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8672.35||||8672.35|2571.35|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|Self-pay|Self-pay|8672.35||||8672.35|3035.32|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8672.35||||8672.35|2571.35|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8672.35||||8672.35|2571.35|5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8672.35||||8672.35||5983.92|2571.35
10809|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX FRA CHANNEL CATHETER 15.7MMx7.5MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8672.35||||8672.35||5983.92|2571.35
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|AARP [1000]|AARP [100000]|3005.53||||3005.53|964.7|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3005.53||||3005.53|161.39|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|AETNA [1015]|AETNA [101529]|3005.53||||3005.53|1187.52|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3005.53||||3005.53|891.14|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3005.53||||3005.53|159.79|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3005.53||||3005.53|159.79|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|BCBS [1155]|BCBS UTHCT [115568]|3005.53||||3005.53|1412.6|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3005.53||||3005.53|0|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3005.53||||3005.53|1502.77|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3005.53||||3005.53|1893.48|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3005.53||||3005.53|891.14|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3005.53||||3005.53|159.79|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|CIGNA [1260]|CIGNA GWH [126023]|3005.53||||3005.53|1502.77|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3005.53||||3005.53|2073.82|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3005.53||||3005.53|68.46|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3005.53||||3005.53|159.79|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3005.53||||3005.53|1187.52|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3005.53||||3005.53|891.14|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3005.53||||3005.53|159.79|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3005.53||||3005.53|1187.52|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3005.53||||3005.53|891.14|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3005.53||||3005.53|891.14|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3005.53||||3005.53|2073.82|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3005.53||||3005.53|891.14|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|Self-pay|Self-pay|3005.53||||3005.53|1051.94|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3005.53||||3005.53|891.14|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3005.53||||3005.53|891.14|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3005.53||||3005.53|964.7|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3005.53||||3005.53|159.79|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3005.53||||3005.53|159.79|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3005.53||||3005.53|964.7|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3005.53||||3005.53|159.79|2073.82|68.46
108096|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FULVESTRANT 250 MG/5 ML INTRAMUSCULAR SYRINGE|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3005.53||||3005.53|319.58|2073.82|68.46
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|AARP [1000]|AARP [100000]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|AETNA [1015]|AETNA [101529]|8827.5||||8827.5|3892.93|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|BCBS [1155]|BCBS UTHCT [115568]|8827.5||||8827.5|4148.93|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8827.5||||8827.5|4413.75|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8827.5||||8827.5|4413.75|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8827.5||||8827.5|5561.33|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|CIGNA [1260]|CIGNA GWH [126023]|8827.5||||8827.5|4855.13|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8827.5||||8827.5|4413.75|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8827.5||||8827.5|3892.93|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|8827.5||||8827.5|2617.35|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|8827.5||||8827.5|6090.98|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|Self-pay|Self-pay|8827.5||||8827.5|3089.62|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8827.5||||8827.5|2617.35|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8827.5||||8827.5|2617.35|6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8827.5||||8827.5||6090.98|2617.35
10810|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|BARRX RFA FOCAL CATHETER 40MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8827.5||||8827.5||6090.98|2617.35
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|AARP [1000]|AARP [100000]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|AETNA [1015]|AETNA [101529]|9114.04||||9114.04|6756.05|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9114.04||||9114.04|2702.31|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|BCBS [1155]|BCBS UTHCT [115568]|9114.04||||9114.04|4283.6|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9114.04||||9114.04|0|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9114.04||||9114.04|4557.02|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9114.04||||9114.04|5741.85|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9114.04||||9114.04|2702.31|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|CIGNA [1260]|CIGNA GWH [126023]|9114.04||||9114.04|4557.02|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9114.04||||9114.04|6288.69|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9114.04||||9114.04|15.15|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9114.04||||9114.04|6756.05|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9114.04||||9114.04|2702.31|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9114.04||||9114.04|6756.05|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9114.04||||9114.04|2702.31|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9114.04||||9114.04|2702.31|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9114.04||||9114.04|6288.69|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9114.04||||9114.04|2702.31|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|Self-pay|Self-pay|9114.04||||9114.04|3189.91|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9114.04||||9114.04|2702.31|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9114.04||||9114.04|2702.31|6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9114.04||||9114.04||6756.05|15.15
108109|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 234 MG/1.5 ML INTRAMUSCULAR SYRINGE|1.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9114.04||||9114.04||6756.05|15.15
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|AARP [1000]|AARP [100000]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|AETNA [1015]|AETNA [101529]|598.95||||598.95|264.14|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|598.95||||598.95|177.59|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|BCBS [1155]|BCBS UTHCT [115568]|598.95||||598.95|281.51|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|598.95||||598.95|299.48|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|598.95||||598.95|299.48|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|598.95||||598.95|377.34|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|598.95||||598.95|177.59|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|CIGNA [1260]|CIGNA GWH [126023]|598.95||||598.95|329.42|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|GROUP PENSION ADMIN [1450]|GPA [145000]|598.95||||598.95|413.28|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|598.95||||598.95|281.51|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|598.95||||598.95|264.14|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|598.95||||598.95|177.59|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|598.95||||598.95|264.14|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|598.95||||598.95|177.59|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|598.95||||598.95|177.59|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|PHCS [1780]|PHCS MULTIPLAN [178000]|598.95||||598.95|413.28|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|598.95||||598.95|177.59|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|Self-pay|Self-pay|598.95||||598.95|209.63|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|598.95||||598.95|177.59|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|598.95||||598.95|177.59|413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|598.95||||598.95||413.28|177.59
10811|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|BILIARY STENT SET|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|598.95||||598.95||413.28|177.59
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|18.6||||18.6|0.96|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.6||||18.6|5.51|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BCBS UTHCT [115568]|18.6||||18.6|8.74|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.6||||18.6|0|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.6||||18.6|9.3|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.6||||18.6|11.72|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.6||||18.6|5.51|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA GWH [126023]|18.6||||18.6|10.23|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.6||||18.6|12.83|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.6||||18.6|0.49|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.6||||18.6|0.96|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.6||||18.6|5.51|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.6||||18.6|0.96|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.6||||18.6|5.51|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.6||||18.6|5.51|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.6||||18.6|12.83|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.6||||18.6|5.51|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|18.6||||18.6|6.51|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.6||||18.6|5.51|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.6||||18.6|5.51|12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.6||||18.6||12.83|0.49
108118|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.6||||18.6||12.83|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|39.06||||39.06|1.92|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.06||||39.06|11.58|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BCBS UTHCT [115568]|39.06||||39.06|18.36|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.06||||39.06|0|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.06||||39.06|19.53|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.06||||39.06|24.61|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.06||||39.06|11.58|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA GWH [126023]|39.06||||39.06|21.48|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.06||||39.06|26.95|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|39.06||||39.06|0.49|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.06||||39.06|1.92|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.06||||39.06|11.58|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.06||||39.06|1.92|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.06||||39.06|11.58|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|39.06||||39.06|11.58|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.06||||39.06|26.95|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.06||||39.06|11.58|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|39.06||||39.06|13.67|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|39.06||||39.06|11.58|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.06||||39.06|11.58|26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.06||||39.06||26.95|0.49
108119|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.06||||39.06||26.95|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AARP [1000]|AARP [100000]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AETNA [1015]|AETNA [101529]|33.95||||33.95|2.88|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.95||||33.95|10.07|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS [1155]|BCBS UTHCT [115568]|33.95||||33.95|15.96|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.95||||33.95|0|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.95||||33.95|16.98|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.95||||33.95|21.39|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.95||||33.95|10.07|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|CIGNA [1260]|CIGNA GWH [126023]|33.95||||33.95|18.67|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33.95||||33.95|23.43|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.95||||33.95|0.49|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.95||||33.95|2.88|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.95||||33.95|10.07|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.95||||33.95|2.88|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.95||||33.95|10.07|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.95||||33.95|10.07|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33.95||||33.95|23.43|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.95||||33.95|10.07|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|Self-pay|Self-pay|33.95||||33.95|11.88|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.95||||33.95|10.07|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.95||||33.95|10.07|23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.95||||33.95||23.43|0.49
108120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|150 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.95||||33.95||23.43|0.49
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|263.5||||263.5|263.5|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|263.5||||263.5||263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|263.5||||263.5|167.04|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|263.5||||263.5|78.13|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|263.5||||263.5||263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|263.5||||263.5||263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|263.5||||263.5|123.85|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|263.5||||263.5|0|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|263.5||||263.5|131.75|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|263.5||||263.5|166.01|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|263.5||||263.5|78.13|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|263.5||||263.5||263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|263.5||||263.5|144.93|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|263.5||||263.5|181.82|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|263.5||||263.5|0.9|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|263.5||||263.5||263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|263.5||||263.5|167.04|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|263.5||||263.5|78.13|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|263.5||||263.5||263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|263.5||||263.5|167.04|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|263.5||||263.5|78.13|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|263.5||||263.5|78.13|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|263.5||||263.5|181.82|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|263.5||||263.5|78.13|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|263.5||||263.5|92.22|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|263.5||||263.5|78.13|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|263.5||||263.5|78.13|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|263.5||||263.5|263.5|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|263.5||||263.5||263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|263.5||||263.5||263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|263.5||||263.5|263.5|263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|263.5||||263.5||263.5|0.9
108122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 80 MG/4 ML (20 MG/ML) INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|263.5||||263.5||263.5|0.9
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|AARP [1000]|AARP [100000]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|AETNA [1015]|AETNA [101529]|112.03||||112.03|49.41|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|112.03||||112.03|33.22|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|112.03||||112.03|52.65|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|112.03||||112.03|0|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|112.03||||112.03|56.02|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|112.03||||112.03|70.58|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|112.03||||112.03|33.22|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|112.03||||112.03|61.62|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|112.03||||112.03|77.3|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|112.03||||112.03|56.02|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|112.03||||112.03|49.41|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|112.03||||112.03|33.22|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|112.03||||112.03|49.41|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|112.03||||112.03|33.22|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|112.03||||112.03|33.22|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|112.03||||112.03|77.3|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|112.03||||112.03|33.22|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|Self-pay|Self-pay|112.03||||112.03|39.21|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|112.03||||112.03|33.22|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|112.03||||112.03|33.22|77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|112.03||||112.03||77.3|33.22
108127|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POLIOVIRUS VACCINE 40 UNIT-8 UNIT-32 UNIT/0.5 ML INJECTION SUSPENSION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|112.03||||112.03||77.3|33.22
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|AARP [1000]|AARP [100000]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|AETNA [1015]|AETNA [101529]|264.19||||264.19|116.51|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264.19||||264.19|78.33|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|BCBS [1155]|BCBS UTHCT [115568]|264.19||||264.19|124.17|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264.19||||264.19|132.09|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264.19||||264.19|132.09|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264.19||||264.19|166.44|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264.19||||264.19|78.33|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|CIGNA [1260]|CIGNA GWH [126023]|264.19||||264.19|145.3|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264.19||||264.19|182.29|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|264.19||||264.19|132.09|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264.19||||264.19|116.51|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264.19||||264.19|78.33|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264.19||||264.19|116.51|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264.19||||264.19|78.33|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|264.19||||264.19|78.33|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264.19||||264.19|182.29|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264.19||||264.19|78.33|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|Self-pay|Self-pay|264.19||||264.19|92.47|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|264.19||||264.19|78.33|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264.19||||264.19|78.33|182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264.19||||264.19||182.29|78.33
10813|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR 2 ROUNDED STIFF 10MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264.19||||264.19||182.29|78.33
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|7.44||||7.44|2.71|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.44||||7.44|2.21|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BCBS UTHCT [115568]|7.44||||7.44|3.5|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.44||||7.44|0|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.44||||7.44|3.72|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.44||||7.44|4.69|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.44||||7.44|2.21|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA GWH [126023]|7.44||||7.44|4.09|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.44||||7.44|5.13|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.44||||7.44|1.24|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.44||||7.44|2.71|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.44||||7.44|2.21|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.44||||7.44|2.71|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.44||||7.44|2.21|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.44||||7.44|2.21|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.44||||7.44|5.13|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.44||||7.44|2.21|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|7.44||||7.44|2.6|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.44||||7.44|2.21|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.44||||7.44|2.21|5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.44||||7.44||5.13|1.24
108130|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 200 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.44||||7.44||5.13|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AARP [1000]|AARP [100000]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AETNA [1015]|AETNA [101529]|21.7||||21.7|5.42|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.7||||21.7|6.43|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BCBS UTHCT [115568]|21.7||||21.7|10.2|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.7||||21.7|0|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.7||||21.7|10.85|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.7||||21.7|13.67|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.7||||21.7|6.43|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|CIGNA [1260]|CIGNA GWH [126023]|21.7||||21.7|11.94|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.7||||21.7|14.97|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.7||||21.7|1.24|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.7||||21.7|5.42|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.7||||21.7|6.43|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.7||||21.7|5.42|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.7||||21.7|6.43|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.7||||21.7|6.43|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.7||||21.7|14.97|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.7||||21.7|6.43|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|Self-pay|Self-pay|21.7||||21.7|7.59|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.7||||21.7|6.43|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.7||||21.7|6.43|14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.7||||21.7||14.97|1.24
108132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CIPROFLOXACIN 400 MG/200 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.7||||21.7||14.97|1.24
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|48.05||||48.05|22.4|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48.05||||48.05||33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|48.05||||48.05|33.36|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48.05||||48.05|14.25|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48.05||||48.05||33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48.05||||48.05||33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|48.05||||48.05|22.58|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48.05||||48.05|0|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48.05||||48.05|24.03|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48.05||||48.05|30.27|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48.05||||48.05|14.25|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48.05||||48.05||33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|48.05||||48.05|26.43|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|48.05||||48.05|33.15|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|48.05||||48.05|1.33|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48.05||||48.05||33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48.05||||48.05|33.36|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48.05||||48.05|14.25|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48.05||||48.05||33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48.05||||48.05|33.36|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48.05||||48.05|14.25|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|48.05||||48.05|14.25|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|48.05||||48.05|33.15|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48.05||||48.05|14.25|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|48.05||||48.05|16.82|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|48.05||||48.05|14.25|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48.05||||48.05|14.25|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48.05||||48.05|22.4|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|48.05||||48.05||33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|48.05||||48.05||33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48.05||||48.05|22.4|33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48.05||||48.05||33.36|1.33
108133|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIKACIN 1,000 MG/4 ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48.05||||48.05||33.36|1.33
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.42||||1.42|0.63|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.42||||1.42|0.42|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.42||||1.42|0.67|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.42||||1.42|0.71|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.42||||1.42|0.71|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.42||||1.42|0.89|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.42||||1.42|0.42|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.42||||1.42|0.78|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.42||||1.42|0.98|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.42||||1.42|0.71|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.42||||1.42|0.63|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.42||||1.42|0.42|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.42||||1.42|0.63|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.42||||1.42|0.42|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.42||||1.42|0.42|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.42||||1.42|0.98|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.42||||1.42|0.42|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.42||||1.42|0.5|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.42||||1.42|0.42|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.42||||1.42|0.42|91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.42||||1.42||91.87|0.42
10814|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.42||||1.42||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|AARP [1000]|AARP [100000]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|AETNA [1015]|AETNA [101529]|133.14||||133.14|58.72|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|133.14||||133.14|39.48|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|BCBS [1155]|BCBS UTHCT [115568]|133.14||||133.14|62.58|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|133.14||||133.14|66.57|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|133.14||||133.14|66.57|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|133.14||||133.14|83.88|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|133.14||||133.14|39.48|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|CIGNA [1260]|CIGNA GWH [126023]|133.14||||133.14|73.23|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|133.14||||133.14|91.87|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|133.14||||133.14|66.57|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|133.14||||133.14|58.72|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|133.14||||133.14|39.48|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|133.14||||133.14|58.72|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|133.14||||133.14|39.48|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|133.14||||133.14|39.48|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|133.14||||133.14|91.87|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|133.14||||133.14|39.48|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|Self-pay|Self-pay|133.14||||133.14|46.6|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|133.14||||133.14|39.48|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|133.14||||133.14|39.48|91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|133.14||||133.14||91.87|0.42
10814|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|CAPTIVATOR SMALL OVAL STIFF 13MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|133.14||||133.14||91.87|0.42
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|AARP [1000]|AARP [100000]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|AETNA [1015]|AETNA [101529]|780.45||||780.45|344.18|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780.45||||780.45|231.4|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|BCBS [1155]|BCBS UTHCT [115568]|780.45||||780.45|366.81|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780.45||||780.45|390.23|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780.45||||780.45|390.23|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780.45||||780.45|491.68|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780.45||||780.45|231.4|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|CIGNA [1260]|CIGNA GWH [126023]|780.45||||780.45|429.25|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780.45||||780.45|538.51|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780.45||||780.45|366.81|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780.45||||780.45|344.18|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780.45||||780.45|231.4|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780.45||||780.45|344.18|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780.45||||780.45|231.4|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780.45||||780.45|231.4|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780.45||||780.45|538.51|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780.45||||780.45|231.4|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|Self-pay|Self-pay|780.45||||780.45|273.16|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780.45||||780.45|231.4|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780.45||||780.45|231.4|538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780.45||||780.45||538.51|231.4
10816|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 10X10|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|AARP [1000]|AARP [100000]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|AETNA [1015]|AETNA [101529]|780.45||||780.45|344.18|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780.45||||780.45|231.4|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|BCBS [1155]|BCBS UTHCT [115568]|780.45||||780.45|366.81|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780.45||||780.45|390.23|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780.45||||780.45|390.23|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780.45||||780.45|491.68|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780.45||||780.45|231.4|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|CIGNA [1260]|CIGNA GWH [126023]|780.45||||780.45|429.25|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780.45||||780.45|538.51|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780.45||||780.45|366.81|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780.45||||780.45|344.18|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780.45||||780.45|231.4|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780.45||||780.45|344.18|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780.45||||780.45|231.4|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780.45||||780.45|231.4|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780.45||||780.45|538.51|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780.45||||780.45|231.4|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|Self-pay|Self-pay|780.45||||780.45|273.16|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780.45||||780.45|231.4|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780.45||||780.45|231.4|538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780.45||||780.45||538.51|231.4
10817|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X5|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|AARP [1000]|AARP [100000]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|AETNA [1015]|AETNA [101529]|780.45||||780.45|344.18|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780.45||||780.45|231.4|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|BCBS [1155]|BCBS UTHCT [115568]|780.45||||780.45|366.81|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780.45||||780.45|390.23|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780.45||||780.45|390.23|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780.45||||780.45|491.68|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780.45||||780.45|231.4|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|CIGNA [1260]|CIGNA GWH [126023]|780.45||||780.45|429.25|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780.45||||780.45|538.51|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780.45||||780.45|366.81|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780.45||||780.45|344.18|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780.45||||780.45|231.4|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780.45||||780.45|344.18|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780.45||||780.45|231.4|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780.45||||780.45|231.4|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780.45||||780.45|538.51|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780.45||||780.45|231.4|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|Self-pay|Self-pay|780.45||||780.45|273.16|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780.45||||780.45|231.4|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780.45||||780.45|231.4|538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780.45||||780.45||538.51|231.4
10818|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 7X7|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780.45||||780.45||538.51|231.4
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|AARP [1000]|AARP [100000]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|AETNA [1015]|AETNA [101529]|1||||1|0.44|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1||||1|0.3|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|BCBS [1155]|BCBS UTHCT [115568]|1||||1|0.47|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1||||1|0.5|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1||||1|0.5|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1||||1|0.63|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1||||1|0.3|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|CIGNA [1260]|CIGNA GWH [126023]|1||||1|0.55|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1||||1|0.69|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1||||1|0.5|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1||||1|0.44|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1||||1|0.3|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1||||1|0.44|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1||||1|0.3|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1||||1|0.3|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1||||1|0.69|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1||||1|0.3|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|Self-pay|Self-pay|1||||1|0.35|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1||||1|0.3|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1||||1|0.3|0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1||||1||0.69|0.3
10819|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|PEDIATRIC BITE BLOCK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1||||1||0.69|0.3
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|AARP [1000]|AARP [100000]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|AETNA [1015]|AETNA [101529]|780.45||||780.45|344.18|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780.45||||780.45|231.4|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|BCBS [1155]|BCBS UTHCT [115568]|780.45||||780.45|366.81|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780.45||||780.45|390.23|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780.45||||780.45|390.23|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780.45||||780.45|491.68|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780.45||||780.45|231.4|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|CIGNA [1260]|CIGNA GWH [126023]|780.45||||780.45|429.25|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780.45||||780.45|538.51|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780.45||||780.45|366.81|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780.45||||780.45|344.18|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780.45||||780.45|231.4|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780.45||||780.45|344.18|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780.45||||780.45|231.4|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780.45||||780.45|231.4|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780.45||||780.45|538.51|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780.45||||780.45|231.4|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|Self-pay|Self-pay|780.45||||780.45|273.16|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780.45||||780.45|231.4|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780.45||||780.45|231.4|538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780.45||||780.45||538.51|231.4
10820|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X5|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|AARP [1000]|AARP [100000]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|AETNA [1015]|AETNA [101529]|780.45||||780.45|344.18|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780.45||||780.45|231.4|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|BCBS [1155]|BCBS UTHCT [115568]|780.45||||780.45|366.81|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780.45||||780.45|390.23|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780.45||||780.45|390.23|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780.45||||780.45|491.68|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780.45||||780.45|231.4|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|CIGNA [1260]|CIGNA GWH [126023]|780.45||||780.45|429.25|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780.45||||780.45|538.51|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780.45||||780.45|366.81|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780.45||||780.45|344.18|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780.45||||780.45|231.4|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780.45||||780.45|344.18|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780.45||||780.45|231.4|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780.45||||780.45|231.4|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780.45||||780.45|538.51|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780.45||||780.45|231.4|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|Self-pay|Self-pay|780.45||||780.45|273.16|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780.45||||780.45|231.4|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780.45||||780.45|231.4|538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780.45||||780.45||538.51|231.4
10821|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X7|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|AARP [1000]|AARP [100000]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|AETNA [1015]|AETNA [101529]|780.45||||780.45|344.18|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780.45||||780.45|231.4|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|BCBS [1155]|BCBS UTHCT [115568]|780.45||||780.45|366.81|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780.45||||780.45|390.23|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780.45||||780.45|390.23|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780.45||||780.45|491.68|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780.45||||780.45|231.4|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|CIGNA [1260]|CIGNA GWH [126023]|780.45||||780.45|429.25|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780.45||||780.45|538.51|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780.45||||780.45|366.81|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780.45||||780.45|344.18|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780.45||||780.45|231.4|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780.45||||780.45|344.18|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780.45||||780.45|231.4|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780.45||||780.45|231.4|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780.45||||780.45|538.51|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780.45||||780.45|231.4|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|Self-pay|Self-pay|780.45||||780.45|273.16|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780.45||||780.45|231.4|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780.45||||780.45|231.4|538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780.45||||780.45||538.51|231.4
10822|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|COTTON LEUNG BILLIARY STENT 8.5X9|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780.45||||780.45||538.51|231.4
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|AARP [1000]|AARP [100000]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|AETNA [1015]|AETNA [101529]|1645.13||||1645.13|725.5|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1645.13||||1645.13|487.78|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|BCBS [1155]|BCBS UTHCT [115568]|1645.13||||1645.13|773.21|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1645.13||||1645.13|822.56|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1645.13||||1645.13|822.56|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1645.13||||1645.13|1036.43|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1645.13||||1645.13|487.78|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|CIGNA [1260]|CIGNA GWH [126023]|1645.13||||1645.13|904.82|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1645.13||||1645.13|1135.14|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1645.13||||1645.13|822.56|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1645.13||||1645.13|725.5|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1645.13||||1645.13|487.78|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1645.13||||1645.13|725.5|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1645.13||||1645.13|487.78|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1645.13||||1645.13|487.78|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1645.13||||1645.13|1135.14|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1645.13||||1645.13|487.78|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|Self-pay|Self-pay|1645.13||||1645.13|575.8|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1645.13||||1645.13|487.78|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1645.13||||1645.13|487.78|1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1645.13||||1645.13||1135.14|487.78
10825|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ECHO-20-C-HD-20-C PROCORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1645.13||||1645.13||1135.14|487.78
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|AARP [1000]|AARP [100000]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|AETNA [1015]|AETNA [101529]|989.75||||989.75|436.48|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|989.75||||989.75|293.46|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|BCBS [1155]|BCBS UTHCT [115568]|989.75||||989.75|465.18|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|989.75||||989.75|494.88|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|989.75||||989.75|494.88|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|989.75||||989.75|623.54|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|989.75||||989.75|293.46|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|CIGNA [1260]|CIGNA GWH [126023]|989.75||||989.75|544.36|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|GROUP PENSION ADMIN [1450]|GPA [145000]|989.75||||989.75|682.93|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|989.75||||989.75|494.88|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|989.75||||989.75|436.48|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|989.75||||989.75|293.46|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|989.75||||989.75|436.48|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|989.75||||989.75|293.46|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|989.75||||989.75|293.46|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|PHCS [1780]|PHCS MULTIPLAN [178000]|989.75||||989.75|682.93|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|989.75||||989.75|293.46|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|Self-pay|Self-pay|989.75||||989.75|346.41|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|989.75||||989.75|293.46|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|989.75||||989.75|293.46|682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|989.75||||989.75||682.93|293.46
10826|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION WIREGUIDED EXTRACTION BASKET|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|989.75||||989.75||682.93|293.46
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|AARP [1000]|AARP [100000]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|AETNA [1015]|AETNA [101529]|250.88||||250.88|110.64|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|250.88||||250.88|74.38|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|BCBS [1155]|BCBS UTHCT [115568]|250.88||||250.88|117.91|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|250.88||||250.88|125.44|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|250.88||||250.88|125.44|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|250.88||||250.88|158.05|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|250.88||||250.88|74.38|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|CIGNA [1260]|CIGNA GWH [126023]|250.88||||250.88|137.98|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|250.88||||250.88|173.1|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|250.88||||250.88|117.91|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|250.88||||250.88|110.64|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|250.88||||250.88|74.38|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|250.88||||250.88|110.64|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|250.88||||250.88|74.38|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|250.88||||250.88|74.38|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|250.88||||250.88|173.1|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|250.88||||250.88|74.38|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|Self-pay|Self-pay|250.88||||250.88|87.81|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|250.88||||250.88|74.38|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|250.88||||250.88|74.38|173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|250.88||||250.88||173.1|74.38
10827|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|MIC-KEY GASTROSTOMY FEEDING TUBE24FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|250.88||||250.88||173.1|74.38
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|AARP [1000]|AARP [100000]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|AETNA [1015]|AETNA [101529]|12.39||||12.39|5.47|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.39||||12.39|3.67|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|BCBS [1155]|BCBS UTHCT [115568]|12.39||||12.39|5.83|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.39||||12.39|6.2|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.39||||12.39|6.2|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.39||||12.39|7.81|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.39||||12.39|3.67|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|CIGNA [1260]|CIGNA GWH [126023]|12.39||||12.39|6.82|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12.39||||12.39|8.55|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.39||||12.39|6.2|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.39||||12.39|5.47|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.39||||12.39|3.67|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.39||||12.39|5.47|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.39||||12.39|3.67|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.39||||12.39|3.67|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12.39||||12.39|8.55|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.39||||12.39|3.67|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|Self-pay|Self-pay|12.39||||12.39|4.33|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.39||||12.39|3.67|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.39||||12.39|3.67|8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.39||||12.39||8.55|3.67
10830|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|COMPLIANCE KIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.39||||12.39||8.55|3.67
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|AARP [1000]|AARP [100000]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|AETNA [1015]|AETNA [101529]|598.95||||598.95|264.14|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|598.95||||598.95|177.59|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|BCBS [1155]|BCBS UTHCT [115568]|598.95||||598.95|281.51|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|598.95||||598.95|299.48|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|598.95||||598.95|299.48|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|598.95||||598.95|377.34|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|598.95||||598.95|177.59|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|CIGNA [1260]|CIGNA GWH [126023]|598.95||||598.95|329.42|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|GROUP PENSION ADMIN [1450]|GPA [145000]|598.95||||598.95|413.28|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|598.95||||598.95|299.48|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|598.95||||598.95|264.14|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|598.95||||598.95|177.59|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|598.95||||598.95|264.14|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|598.95||||598.95|177.59|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|598.95||||598.95|177.59|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|PHCS [1780]|PHCS MULTIPLAN [178000]|598.95||||598.95|413.28|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|598.95||||598.95|177.59|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|Self-pay|Self-pay|598.95||||598.95|209.63|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|598.95||||598.95|177.59|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|598.95||||598.95|177.59|413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|598.95||||598.95||413.28|177.59
10831|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SOEHENDRA BILIARY DILATION CATHETER 6FR 200CM .035|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|598.95||||598.95||413.28|177.59
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|AARP [1000]|AARP [100000]|696.96||||696.96|313.63|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|696.96||||696.96||480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|AETNA [1015]|AETNA [101529]|696.96||||696.96|307.36|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|696.96||||696.96|206.65|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|696.96||||696.96||480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|696.96||||696.96||480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|BCBS [1155]|BCBS UTHCT [115568]|696.96||||696.96|327.57|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|696.96||||696.96|348.48|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|696.96||||696.96|348.48|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|696.96||||696.96|439.08|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|696.96||||696.96|206.65|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|696.96||||696.96||480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|CIGNA [1260]|CIGNA GWH [126023]|696.96||||696.96|383.33|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|GROUP PENSION ADMIN [1450]|GPA [145000]|696.96||||696.96|480.9|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|696.96||||696.96|348.48|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|696.96||||696.96||480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|696.96||||696.96|307.36|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|696.96||||696.96|206.65|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|696.96||||696.96||480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|696.96||||696.96|307.36|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|696.96||||696.96|206.65|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|696.96||||696.96|206.65|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|PHCS [1780]|PHCS MULTIPLAN [178000]|696.96||||696.96|480.9|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|696.96||||696.96|206.65|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|Self-pay|Self-pay|696.96||||696.96|243.94|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|696.96||||696.96|206.65|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|696.96||||696.96|206.65|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|696.96||||696.96|313.63|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|696.96||||696.96||480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|696.96||||696.96||480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|696.96||||696.96|313.63|480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|696.96||||696.96||480.9|206.65
10832|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 7|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|AARP [1000]|AARP [100000]|696.96||||696.96|313.63|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|AETNA [1015]|AETNA [101529]|696.96||||696.96|307.36|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|696.96||||696.96|206.65|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|BCBS [1155]|BCBS UTHCT [115568]|696.96||||696.96|327.57|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|696.96||||696.96|348.48|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|696.96||||696.96|348.48|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|696.96||||696.96|439.08|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|696.96||||696.96|206.65|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|CIGNA [1260]|CIGNA GWH [126023]|696.96||||696.96|383.33|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|GROUP PENSION ADMIN [1450]|GPA [145000]|696.96||||696.96|480.9|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|696.96||||696.96|348.48|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|696.96||||696.96|307.36|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|696.96||||696.96|206.65|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|696.96||||696.96|307.36|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|696.96||||696.96|206.65|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|696.96||||696.96|206.65|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|PHCS [1780]|PHCS MULTIPLAN [178000]|696.96||||696.96|480.9|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|696.96||||696.96|206.65|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|Self-pay|Self-pay|696.96||||696.96|243.94|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|696.96||||696.96|206.65|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|696.96||||696.96|206.65|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|696.96||||696.96|313.63|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|696.96||||696.96|313.63|480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|696.96||||696.96||480.9|206.65
10833|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|MARCON COLON DECOMRESSION SET 10|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|696.96||||696.96||480.9|206.65
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|AARP [1000]|AARP [100000]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|AETNA [1015]|AETNA [101529]|664.77||||664.77|293.17|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|664.77||||664.77|197.11|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|BCBS [1155]|BCBS UTHCT [115568]|664.77||||664.77|312.44|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|664.77||||664.77|332.39|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|664.77||||664.77|332.39|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|664.77||||664.77|418.81|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|664.77||||664.77|197.11|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|CIGNA [1260]|CIGNA GWH [126023]|664.77||||664.77|365.63|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|664.77||||664.77|458.69|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|664.77||||664.77|332.39|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|664.77||||664.77|293.17|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|664.77||||664.77|197.11|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|664.77||||664.77|293.17|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|664.77||||664.77|197.11|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|664.77||||664.77|197.11|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|664.77||||664.77|458.69|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|664.77||||664.77|197.11|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|Self-pay|Self-pay|664.77||||664.77|232.67|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|664.77||||664.77|197.11|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|664.77||||664.77|197.11|458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|664.77||||664.77||458.69|197.11
10834|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|QUANTUM BILIARY INFLATION DEVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|664.77||||664.77||458.69|197.11
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|AARP [1000]|AARP [100000]|352.11||||352.11|158.45|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|352.11||||352.11||242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|AETNA [1015]|AETNA [101529]|352.11||||352.11|155.28|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|352.11||||352.11|104.4|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|352.11||||352.11||242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|352.11||||352.11||242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|BCBS [1155]|BCBS UTHCT [115568]|352.11||||352.11|165.49|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|352.11||||352.11|176.06|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|352.11||||352.11|176.06|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|352.11||||352.11|221.83|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|352.11||||352.11|104.4|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|352.11||||352.11||242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|CIGNA [1260]|CIGNA GWH [126023]|352.11||||352.11|193.66|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|GROUP PENSION ADMIN [1450]|GPA [145000]|352.11||||352.11|242.96|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|352.11||||352.11|176.06|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|352.11||||352.11||242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|352.11||||352.11|155.28|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|352.11||||352.11|104.4|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|352.11||||352.11||242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|352.11||||352.11|155.28|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|352.11||||352.11|104.4|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|352.11||||352.11|104.4|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|PHCS [1780]|PHCS MULTIPLAN [178000]|352.11||||352.11|242.96|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|352.11||||352.11|104.4|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|Self-pay|Self-pay|352.11||||352.11|123.24|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|352.11||||352.11|104.4|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|352.11||||352.11|104.4|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|352.11||||352.11|158.45|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|352.11||||352.11||242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|352.11||||352.11||242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|352.11||||352.11|158.45|242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|352.11||||352.11||242.96|104.4
10835|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 8.5|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|AARP [1000]|AARP [100000]|352.11||||352.11|158.45|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|AETNA [1015]|AETNA [101529]|352.11||||352.11|155.28|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|352.11||||352.11|104.4|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|BCBS [1155]|BCBS UTHCT [115568]|352.11||||352.11|165.49|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|352.11||||352.11|176.06|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|352.11||||352.11|176.06|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|352.11||||352.11|221.83|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|352.11||||352.11|104.4|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|CIGNA [1260]|CIGNA GWH [126023]|352.11||||352.11|193.66|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|352.11||||352.11|242.96|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|352.11||||352.11|176.06|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|352.11||||352.11|155.28|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|352.11||||352.11|104.4|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|352.11||||352.11|155.28|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|352.11||||352.11|104.4|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|352.11||||352.11|104.4|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|352.11||||352.11|242.96|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|352.11||||352.11|104.4|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|Self-pay|Self-pay|352.11||||352.11|123.24|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|352.11||||352.11|104.4|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|352.11||||352.11|104.4|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|352.11||||352.11|158.45|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|352.11||||352.11|158.45|242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|352.11||||352.11||242.96|104.4
10836|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ONE ACTION STENT INTODUCTION SYSTEM 10FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|AARP [1000]|AARP [100000]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|AETNA [1015]|AETNA [101529]|352.11||||352.11|155.28|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|352.11||||352.11|104.4|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|BCBS [1155]|BCBS UTHCT [115568]|352.11||||352.11|165.49|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|352.11||||352.11|176.06|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|352.11||||352.11|176.06|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|352.11||||352.11|221.83|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|352.11||||352.11|104.4|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|CIGNA [1260]|CIGNA GWH [126023]|352.11||||352.11|193.66|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|352.11||||352.11|242.96|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|352.11||||352.11|176.06|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|352.11||||352.11|155.28|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|352.11||||352.11|104.4|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|352.11||||352.11|155.28|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|352.11||||352.11|104.4|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|352.11||||352.11|104.4|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|352.11||||352.11|242.96|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|352.11||||352.11|104.4|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|Self-pay|Self-pay|352.11||||352.11|123.24|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|352.11||||352.11|104.4|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|352.11||||352.11|104.4|242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|352.11||||352.11||242.96|104.4
10837|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSHION PUSHING CATHETER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|352.11||||352.11||242.96|104.4
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AARP [1000]|AARP [100000]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AETNA [1015]|AETNA [101529]|37.2||||37.2|16.41|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.2||||37.2|11.03|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS [1155]|BCBS UTHCT [115568]|37.2||||37.2|17.48|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.2||||37.2|18.6|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.2||||37.2|18.6|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.2||||37.2|23.44|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.2||||37.2|11.03|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|CIGNA [1260]|CIGNA GWH [126023]|37.2||||37.2|20.46|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|37.2||||37.2|25.67|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|37.2||||37.2|18.6|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.2||||37.2|16.41|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.2||||37.2|11.03|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.2||||37.2|16.41|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.2||||37.2|11.03|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|37.2||||37.2|11.03|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|37.2||||37.2|25.67|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.2||||37.2|11.03|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|Self-pay|Self-pay|37.2||||37.2|13.02|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|37.2||||37.2|11.03|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.2||||37.2|11.03|860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.2||||37.2||860.12|11.03
10839|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION|4,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.2||||37.2||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|AARP [1000]|AARP [100000]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|AETNA [1015]|AETNA [101529]|1246.55||||1246.55|549.73|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1246.55||||1246.55|369.6|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|BCBS [1155]|BCBS UTHCT [115568]|1246.55||||1246.55|585.88|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1246.55||||1246.55|623.28|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1246.55||||1246.55|623.28|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1246.55||||1246.55|785.33|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1246.55||||1246.55|369.6|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|CIGNA [1260]|CIGNA GWH [126023]|1246.55||||1246.55|685.6|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1246.55||||1246.55|860.12|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1246.55||||1246.55|623.28|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1246.55||||1246.55|549.73|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1246.55||||1246.55|369.6|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1246.55||||1246.55|549.73|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1246.55||||1246.55|369.6|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1246.55||||1246.55|369.6|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1246.55||||1246.55|860.12|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1246.55||||1246.55|369.6|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|Self-pay|Self-pay|1246.55||||1246.55|436.29|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1246.55||||1246.55|369.6|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1246.55||||1246.55|369.6|860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1246.55||||1246.55||860.12|11.03
10839|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FUSION TITAN BILIARY DILATION BALLOON 8MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1246.55||||1246.55||860.12|11.03
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|AARP [1000]|AARP [100000]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|AETNA [1015]|AETNA [101529]|277.64||||277.64|122.44|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.64||||277.64|82.32|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|BCBS [1155]|BCBS UTHCT [115568]|277.64||||277.64|130.49|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.64||||277.64|138.82|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.64||||277.64|138.82|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.64||||277.64|174.91|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.64||||277.64|82.32|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|CIGNA [1260]|CIGNA GWH [126023]|277.64||||277.64|152.7|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277.64||||277.64|191.57|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|277.64||||277.64|138.82|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.64||||277.64|122.44|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.64||||277.64|82.32|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.64||||277.64|122.44|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.64||||277.64|82.32|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|277.64||||277.64|82.32|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277.64||||277.64|191.57|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.64||||277.64|82.32|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|Self-pay|Self-pay|277.64||||277.64|97.18|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|277.64||||277.64|82.32|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.64||||277.64|82.32|191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.64||||277.64||191.57|82.32
10840|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 18 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277.64||||277.64||191.57|82.32
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|AARP [1000]|AARP [100000]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|AETNA [1015]|AETNA [101529]|433.3||||433.3|191.09|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|433.3||||433.3|128.47|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|BCBS [1155]|BCBS UTHCT [115568]|433.3||||433.3|203.65|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|433.3||||433.3|216.65|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|433.3||||433.3|216.65|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|433.3||||433.3|272.98|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|433.3||||433.3|128.47|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|CIGNA [1260]|CIGNA GWH [126023]|433.3||||433.3|238.32|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|433.3||||433.3|298.98|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|433.3||||433.3|216.65|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|433.3||||433.3|191.09|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|433.3||||433.3|128.47|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|433.3||||433.3|191.09|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|433.3||||433.3|128.47|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|433.3||||433.3|128.47|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|433.3||||433.3|298.98|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|433.3||||433.3|128.47|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|Self-pay|Self-pay|433.3||||433.3|151.65|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|433.3||||433.3|128.47|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|433.3||||433.3|128.47|298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|433.3||||433.3||298.98|128.47
10841|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|GASTROSTOMY BR BALLOON RETENTION FEEDING TUBE 20 FR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|433.3||||433.3||298.98|128.47
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|AARP [1000]|AARP [100000]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|AETNA [1015]|AETNA [101529]|197.36||||197.36|87.03|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|197.36||||197.36|58.52|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|BCBS [1155]|BCBS UTHCT [115568]|197.36||||197.36|92.76|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|197.36||||197.36|98.68|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|197.36||||197.36|98.68|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|197.36||||197.36|124.33|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|197.36||||197.36|58.52|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|CIGNA [1260]|CIGNA GWH [126023]|197.36||||197.36|108.55|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|197.36||||197.36|136.17|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|197.36||||197.36|98.68|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|197.36||||197.36|87.03|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|197.36||||197.36|58.52|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|197.36||||197.36|87.03|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|197.36||||197.36|58.52|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|197.36||||197.36|58.52|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|197.36||||197.36|136.17|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|197.36||||197.36|58.52|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|Self-pay|Self-pay|197.36||||197.36|69.08|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|197.36||||197.36|58.52|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|197.36||||197.36|58.52|136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|197.36||||197.36||136.17|58.52
10842|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SPOT TATTOO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|197.36||||197.36||136.17|58.52
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|AARP [1000]|AARP [100000]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|AETNA [1015]|AETNA [101529]|87.9||||87.9|38.76|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|87.9||||87.9|26.06|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|BCBS [1155]|BCBS UTHCT [115568]|87.9||||87.9|41.31|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|87.9||||87.9|43.95|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|87.9||||87.9|43.95|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|87.9||||87.9|55.38|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|87.9||||87.9|26.06|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|CIGNA [1260]|CIGNA GWH [126023]|87.9||||87.9|48.35|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|GROUP PENSION ADMIN [1450]|GPA [145000]|87.9||||87.9|60.65|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|87.9||||87.9|43.95|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|87.9||||87.9|38.76|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|87.9||||87.9|26.06|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|87.9||||87.9|38.76|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|87.9||||87.9|26.06|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|87.9||||87.9|26.06|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|PHCS [1780]|PHCS MULTIPLAN [178000]|87.9||||87.9|60.65|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|87.9||||87.9|26.06|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|Self-pay|Self-pay|87.9||||87.9|30.76|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|87.9||||87.9|26.06|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|87.9||||87.9|26.06|60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|87.9||||87.9||60.65|26.06
10844|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|LMA GASTRO CUFF PILOT SIZE 4|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|87.9||||87.9||60.65|26.06
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|AARP [1000]|AARP [100000]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|AETNA [1015]|AETNA [101529]|586.06||||586.06|258.45|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|586.06||||586.06|173.77|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|BCBS [1155]|BCBS UTHCT [115568]|586.06||||586.06|275.45|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|586.06||||586.06|293.03|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|586.06||||586.06|293.03|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|586.06||||586.06|369.22|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|586.06||||586.06|173.77|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|CIGNA [1260]|CIGNA GWH [126023]|586.06||||586.06|322.33|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|586.06||||586.06|404.38|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|586.06||||586.06|293.03|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|586.06||||586.06|258.45|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|586.06||||586.06|173.77|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|586.06||||586.06|258.45|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|586.06||||586.06|173.77|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|586.06||||586.06|173.77|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|586.06||||586.06|404.38|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|586.06||||586.06|173.77|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|Self-pay|Self-pay|586.06||||586.06|205.12|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|586.06||||586.06|173.77|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|586.06||||586.06|173.77|404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|586.06||||586.06||404.38|173.77
10845|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|RADIAL JAW 4 JUMBO BIOSY FORCEP 3.2MM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|586.06||||586.06||404.38|173.77
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|AARP [1000]|AARP [100000]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|AETNA [1015]|AETNA [101529]|500.94||||500.94|220.91|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|500.94||||500.94|148.53|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|BCBS [1155]|BCBS UTHCT [115568]|500.94||||500.94|235.44|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|500.94||||500.94|250.47|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|500.94||||500.94|250.47|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|500.94||||500.94|315.59|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|500.94||||500.94|148.53|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|CIGNA [1260]|CIGNA GWH [126023]|500.94||||500.94|275.52|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|500.94||||500.94|345.65|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|500.94||||500.94|250.47|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|500.94||||500.94|220.91|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|500.94||||500.94|148.53|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|500.94||||500.94|220.91|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|500.94||||500.94|148.53|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|500.94||||500.94|148.53|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|500.94||||500.94|345.65|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|500.94||||500.94|148.53|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|Self-pay|Self-pay|500.94||||500.94|175.33|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|500.94||||500.94|148.53|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|500.94||||500.94|148.53|345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|500.94||||500.94||345.65|148.53
10846|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|SENSATION SHORT THROW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|500.94||||500.94||345.65|148.53
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|AARP [1000]|AARP [100000]|12092.44||||12092.44|0|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12092.44||||12092.44||8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|AETNA [1015]|AETNA [101529]|12092.44||||12092.44|3748.66|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12092.44||||12092.44|3585.41|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12092.44||||12092.44||8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12092.44||||12092.44||8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|BCBS [1155]|BCBS UTHCT [115568]|12092.44||||12092.44|5683.45|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12092.44||||12092.44|6046.22|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12092.44||||12092.44|6046.22|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12092.44||||12092.44|7618.24|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12092.44||||12092.44|3585.41|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12092.44||||12092.44||8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|CIGNA [1260]|CIGNA GWH [126023]|12092.44||||12092.44|6046.22|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12092.44||||12092.44|8343.79|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12092.44||||12092.44|5683.45|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12092.44||||12092.44||8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12092.44||||12092.44|3748.66|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12092.44||||12092.44|3585.41|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12092.44||||12092.44||8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12092.44||||12092.44|3748.66|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12092.44||||12092.44|3585.41|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|12092.44||||12092.44|3585.41|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12092.44||||12092.44|8343.79|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12092.44||||12092.44|3585.41|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|Self-pay|Self-pay|12092.44||||12092.44|4232.35|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12092.44||||12092.44|3585.41|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12092.44||||12092.44|3585.41|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12092.44||||12092.44|0|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12092.44||||12092.44||8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12092.44||||12092.44||8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12092.44||||12092.44|0|8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12092.44||||12092.44||8343.79|3585.41
10847|SUP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|WALLFLEX BILIARY RX FULLY COVERED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12092.44||||12092.44||8343.79|3585.41
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|AARP [1000]|AARP [100000]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|AETNA [1015]|AETNA [101529]|145.64||||145.64|64.23|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|145.64||||145.64|43.18|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|BCBS [1155]|BCBS UTHCT [115568]|145.64||||145.64|68.45|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|145.64||||145.64|72.82|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|145.64||||145.64|72.82|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|145.64||||145.64|91.75|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|145.64||||145.64|43.18|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|CIGNA [1260]|CIGNA GWH [126023]|145.64||||145.64|80.1|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|145.64||||145.64|100.49|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|145.64||||145.64|72.82|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|145.64||||145.64|64.23|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|145.64||||145.64|43.18|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|145.64||||145.64|64.23|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|145.64||||145.64|43.18|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|145.64||||145.64|43.18|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|145.64||||145.64|100.49|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|145.64||||145.64|43.18|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|Self-pay|Self-pay|145.64||||145.64|50.98|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|145.64||||145.64|43.18|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|145.64||||145.64|43.18|100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|145.64||||145.64||100.49|43.18
10848|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON RADIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|145.64||||145.64||100.49|43.18
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|AARP [1000]|AARP [100000]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|AETNA [1015]|AETNA [101529]|143.9||||143.9|63.46|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|143.9||||143.9|42.67|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|BCBS [1155]|BCBS UTHCT [115568]|143.9||||143.9|67.63|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|143.9||||143.9|71.95|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|143.9||||143.9|71.95|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|143.9||||143.9|90.66|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|143.9||||143.9|42.67|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|CIGNA [1260]|CIGNA GWH [126023]|143.9||||143.9|79.15|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|143.9||||143.9|99.29|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|143.9||||143.9|71.95|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|143.9||||143.9|63.46|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|143.9||||143.9|42.67|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|143.9||||143.9|63.46|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|143.9||||143.9|42.67|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|143.9||||143.9|42.67|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|143.9||||143.9|99.29|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|143.9||||143.9|42.67|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|Self-pay|Self-pay|143.9||||143.9|50.36|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|143.9||||143.9|42.67|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|143.9||||143.9|42.67|99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|143.9||||143.9||99.29|42.67
10849|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|OLYMPUS BALLOON LINEAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|143.9||||143.9||99.29|42.67
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|AARP [1000]|AARP [100000]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|AETNA [1015]|AETNA [101529]|71.46||||71.46|31.52|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.46||||71.46|21.19|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|BCBS [1155]|BCBS UTHCT [115568]|71.46||||71.46|33.59|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.46||||71.46|35.73|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.46||||71.46|35.73|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.46||||71.46|45.02|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.46||||71.46|21.19|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|CIGNA [1260]|CIGNA GWH [126023]|71.46||||71.46|39.3|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71.46||||71.46|49.31|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71.46||||71.46|35.73|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.46||||71.46|31.52|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.46||||71.46|21.19|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.46||||71.46|31.52|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.46||||71.46|21.19|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|71.46||||71.46|21.19|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71.46||||71.46|49.31|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.46||||71.46|21.19|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|Self-pay|Self-pay|71.46||||71.46|25.01|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71.46||||71.46|21.19|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.46||||71.46|21.19|49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.46||||71.46||49.31|21.19
10851|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|FLEXICARE (DUAL ADULT NASAL CANNULA) 14 FT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.46||||71.46||49.31|21.19
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|AARP [1000]|AARP [100000]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|AETNA [1015]|AETNA [101529]|605||||605|266.81|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|605||||605|179.38|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|BCBS [1155]|BCBS UTHCT [115568]|605||||605|284.35|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|605||||605|302.5|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|605||||605|302.5|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|605||||605|381.15|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|605||||605|179.38|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|CIGNA [1260]|CIGNA GWH [126023]|605||||605|332.75|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|605||||605|417.45|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|605||||605|302.5|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|605||||605|266.81|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|605||||605|179.38|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|605||||605|266.81|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|605||||605|179.38|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|605||||605|179.38|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|605||||605|417.45|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|605||||605|179.38|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|Self-pay|Self-pay|605||||605|211.75|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|605||||605|179.38|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|605||||605|179.38|417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|605||||605||417.45|179.38
10853|SUP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|ROTH NET FOREIGN BODY, PLATINUM UNIVERSAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|605||||605||417.45|179.38
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.01||||1.01|0.45|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.01||||1.01|0.3|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.01||||1.01|0.47|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.01||||1.01|0.51|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.01||||1.01|0.51|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.01||||1.01|0.64|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.01||||1.01|0.3|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.01||||1.01|0.56|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.01||||1.01|0.7|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.01||||1.01|0.51|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.01||||1.01|0.45|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.01||||1.01|0.3|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.01||||1.01|0.45|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.01||||1.01|0.3|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.01||||1.01|0.3|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.01||||1.01|0.7|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.01||||1.01|0.3|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|Self-pay|Self-pay|1.01||||1.01|0.35|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.01||||1.01|0.3|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.01||||1.01|0.3|0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.01||||1.01||0.7|0.3
10855|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.01||||1.01||0.7|0.3
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.56||||0.56|0.25|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.56||||0.56|0.17|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.56||||0.56|0.26|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.56||||0.56|0.28|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.56||||0.56|0.28|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.56||||0.56|0.35|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.56||||0.56|0.17|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.56||||0.56|0.31|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.56||||0.56|0.39|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.56||||0.56|0.28|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.56||||0.56|0.25|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.56||||0.56|0.17|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.56||||0.56|0.25|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.56||||0.56|0.17|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.56||||0.56|0.17|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.56||||0.56|0.39|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.56||||0.56|0.17|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|Self-pay|Self-pay|0.56||||0.56|0.2|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.56||||0.56|0.17|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.56||||0.56|0.17|0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.56||||0.56||0.39|0.17
10856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.56||||0.56||0.39|0.17
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|425.26||||425.26|116.16|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|425.26||||425.26|126.09|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|425.26||||425.26|199.87|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|425.26||||425.26|0|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|425.26||||425.26|212.63|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|425.26||||425.26|267.91|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|425.26||||425.26|126.09|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|425.26||||425.26|233.89|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|425.26||||425.26|293.43|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|425.26||||425.26|1.4|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|425.26||||425.26|116.16|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|425.26||||425.26|126.09|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|425.26||||425.26|116.16|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|425.26||||425.26|126.09|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|425.26||||425.26|126.09|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|425.26||||425.26|293.43|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|425.26||||425.26|126.09|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|425.26||||425.26|148.84|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|425.26||||425.26|126.09|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|425.26||||425.26|126.09|293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|425.26||||425.26||293.43|1.4
108590|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|425.26||||425.26||293.43|1.4
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.3||||0.3|0.13|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.3||||0.3|0.09|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.3||||0.3|0.14|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.3||||0.3|0.15|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.3||||0.3|0.15|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.3||||0.3|0.19|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.3||||0.3|0.09|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.3||||0.3|0.17|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.3||||0.3|0.21|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.3||||0.3|0.15|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.3||||0.3|0.13|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.3||||0.3|0.09|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.3||||0.3|0.13|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.3||||0.3|0.09|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.3||||0.3|0.09|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.3||||0.3|0.21|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.3||||0.3|0.09|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|0.3||||0.3|0.1|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.3||||0.3|0.09|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.3||||0.3|0.09|0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.3||||0.3||0.21|0.09
10863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.3||||0.3||0.21|0.09
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|AARP [1000]|AARP [100000]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|AETNA [1015]|AETNA [101529]|15611.62||||15611.62|0|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15611.62||||15611.62|4628.85|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|BCBS [1155]|BCBS UTHCT [115568]|15611.62||||15611.62|7337.46|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15611.62||||15611.62|0|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15611.62||||15611.62|7805.81|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15611.62||||15611.62|9835.32|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15611.62||||15611.62|4628.85|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|CIGNA [1260]|CIGNA GWH [126023]|15611.62||||15611.62|8586.39|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|15611.62||||15611.62|10772.02|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15611.62||||15611.62|7805.81|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15611.62||||15611.62|0|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15611.62||||15611.62|4628.85|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15611.62||||15611.62|0|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15611.62||||15611.62|4628.85|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|15611.62||||15611.62|4628.85|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|15611.62||||15611.62|10772.02|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15611.62||||15611.62|4628.85|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|Self-pay|Self-pay|15611.62||||15611.62|5464.07|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15611.62||||15611.62|4628.85|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15611.62||||15611.62|4628.85|10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15611.62||||15611.62||10772.02|4628.85
108781|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IOFLUPANE (DATSCAN) PER DOSE UP TO 5 MCI|5 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15611.62||||15611.62||10772.02|4628.85
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|59.28||||59.28|26.14|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|59.28||||59.28|26.14|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|59.28||||59.28|27.86|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|59.28||||59.28|27.86|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.28||||59.28|29.64|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.28||||59.28|29.64|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.28||||59.28|29.64|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.28||||59.28|29.64|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.28||||59.28|37.35|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.28||||59.28|37.35|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|59.28||||59.28|32.6|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|59.28||||59.28|32.6|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.28||||59.28|40.9|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.28||||59.28|40.9|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|59.28||||59.28|29.64|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|59.28||||59.28|29.64|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.28||||59.28|26.14|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.28||||59.28|26.14|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.28||||59.28|26.14|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.28||||59.28|26.14|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.28||||59.28|40.9|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.28||||59.28|40.9|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|59.28||||59.28|20.75|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|59.28||||59.28|20.75|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.28||||59.28|17.58|40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.28||||59.28||40.9|17.58
108804|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RUFINAMIDE 40 MG/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.28||||59.28||40.9|17.58
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|AARP [1000]|AARP [100000]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|AETNA [1015]|AETNA [101529]|1730.61||||1730.61|1329.7|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1730.61||||1730.61|513.13|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|BCBS [1155]|BCBS UTHCT [115568]|1730.61||||1730.61|813.39|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1730.61||||1730.61|0|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1730.61||||1730.61|865.31|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1730.61||||1730.61|1090.28|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1730.61||||1730.61|513.13|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|CIGNA [1260]|CIGNA GWH [126023]|1730.61||||1730.61|865.31|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1730.61||||1730.61|1194.12|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1730.61||||1730.61|58.55|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1730.61||||1730.61|1329.7|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1730.61||||1730.61|513.13|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1730.61||||1730.61|1329.7|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1730.61||||1730.61|513.13|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|1730.61||||1730.61|513.13|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1730.61||||1730.61|1194.12|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1730.61||||1730.61|513.13|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|Self-pay|Self-pay|1730.61||||1730.61|605.71|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1730.61||||1730.61|513.13|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1730.61||||1730.61|513.13|1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1730.61||||1730.61||1329.7|58.55
108842|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 120 MG INTRAVENOUS SOLUTION|120 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1730.61||||1730.61||1329.7|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AARP [1000]|AARP [100000]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AETNA [1015]|AETNA [101529]|5768.48||||5768.48|4432.32|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5768.48||||5768.48|1710.35|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BCBS UTHCT [115568]|5768.48||||5768.48|2711.19|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5768.48||||5768.48|0|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5768.48||||5768.48|2884.24|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5768.48||||5768.48|3634.14|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5768.48||||5768.48|1710.35|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA [1260]|CIGNA GWH [126023]|5768.48||||5768.48|2884.24|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|5768.48||||5768.48|3980.25|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5768.48||||5768.48|58.55|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5768.48||||5768.48|4432.32|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5768.48||||5768.48|1710.35|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5768.48||||5768.48|4432.32|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5768.48||||5768.48|1710.35|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|5768.48||||5768.48|1710.35|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|5768.48||||5768.48|3980.25|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5768.48||||5768.48|1710.35|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|Self-pay|Self-pay|5768.48||||5768.48|2018.97|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5768.48||||5768.48|1710.35|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5768.48||||5768.48|1710.35|4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5768.48||||5768.48||4432.32|58.55
108843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BELIMUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5768.48||||5768.48||4432.32|58.55
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|AARP [1000]|AARP [100000]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|AETNA [1015]|AETNA [101529]|0.5||||0.5|0.22|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.5||||0.5|0.15|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.5||||0.5|0.24|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.5||||0.5|0.25|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.5||||0.5|0.25|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.5||||0.5|0.32|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.5||||0.5|0.15|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.5||||0.5|0.28|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.5||||0.5|0.35|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.5||||0.5|0.25|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.5||||0.5|0.22|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.5||||0.5|0.15|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.5||||0.5|0.22|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.5||||0.5|0.15|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.5||||0.5|0.15|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.5||||0.5|0.35|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.5||||0.5|0.15|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|Self-pay|Self-pay|0.5||||0.5|0.17|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.5||||0.5|0.15|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.5||||0.5|0.15|0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.5||||0.5||0.35|0.15
108850|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE|3 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.5||||0.5||0.35|0.15
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|AARP [1000]|AARP [100000]|1781.14||||1781.14|1595.2|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1781.14||||1781.14||1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|AETNA [1015]|AETNA [101529]|1781.14||||1781.14|334.08|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1781.14||||1781.14|528.11|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1781.14||||1781.14||1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1781.14||||1781.14||1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|BCBS [1155]|BCBS UTHCT [115568]|1781.14||||1781.14|837.14|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1781.14||||1781.14|0|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1781.14||||1781.14|890.57|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1781.14||||1781.14|1122.12|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1781.14||||1781.14|528.11|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1781.14||||1781.14||1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|CIGNA [1260]|CIGNA GWH [126023]|1781.14||||1781.14|890.57|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1781.14||||1781.14|1228.99|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1781.14||||1781.14|0.9|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1781.14||||1781.14||1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1781.14||||1781.14|334.08|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1781.14||||1781.14|528.11|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1781.14||||1781.14||1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1781.14||||1781.14|334.08|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1781.14||||1781.14|528.11|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1781.14||||1781.14|528.11|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1781.14||||1781.14|1228.99|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1781.14||||1781.14|528.11|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|Self-pay|Self-pay|1781.14||||1781.14|623.4|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1781.14||||1781.14|528.11|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1781.14||||1781.14|528.11|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1781.14||||1781.14|1595.2|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1781.14||||1781.14||1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1781.14||||1781.14||1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1781.14||||1781.14|1595.2|1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1781.14||||1781.14||1595.2|0.9
108908|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/16 ML (10 MG/ML) INTRAVENOUS SOLUTION|16 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1781.14||||1781.14||1595.2|0.9
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|23957.24||||23957.24|11978.62|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23957.24||||23957.24|8011.72|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|23957.24||||23957.24|18874.8|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23957.24||||23957.24|7103.32|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23957.24||||23957.24|7932.4|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23957.24||||23957.24|7932.4|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|23957.24||||23957.24|11259.9|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23957.24||||23957.24|0|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23957.24||||23957.24|11978.62|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23957.24||||23957.24|15093.06|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23957.24||||23957.24|7103.32|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23957.24||||23957.24|7932.4|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|23957.24||||23957.24|11978.62|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23957.24||||23957.24|16530.5|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23957.24||||23957.24|196.54|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23957.24||||23957.24|7932.4|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23957.24||||23957.24|18874.8|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23957.24||||23957.24|7103.32|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23957.24||||23957.24|7932.4|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23957.24||||23957.24|18874.8|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23957.24||||23957.24|7103.32|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|23957.24||||23957.24|7103.32|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23957.24||||23957.24|16530.5|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23957.24||||23957.24|7103.32|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|23957.24||||23957.24|8385.03|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23957.24||||23957.24|7103.32|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23957.24||||23957.24|7103.32|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23957.24||||23957.24|11978.62|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23957.24||||23957.24|7932.4|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23957.24||||23957.24|7932.4|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23957.24||||23957.24|11978.62|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23957.24||||23957.24|7932.4|18874.8|196.54
108955|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23957.24||||23957.24|15864.8|18874.8|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|AARP [1000]|AARP [100000]|95828.69||||95828.69|47914.35|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|95828.69||||95828.69|32046.9|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|AETNA [1015]|AETNA [101529]|95828.69||||95828.69|75499.2|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95828.69||||95828.69|28413.21|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95828.69||||95828.69|31729.6|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|95828.69||||95828.69|31729.6|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|BCBS [1155]|BCBS UTHCT [115568]|95828.69||||95828.69|45039.48|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|95828.69||||95828.69|0|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|95828.69||||95828.69|47914.35|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|95828.69||||95828.69|60372.07|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|95828.69||||95828.69|28413.21|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|95828.69||||95828.69|31729.6|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|CIGNA [1260]|CIGNA GWH [126023]|95828.69||||95828.69|47914.35|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|95828.69||||95828.69|66121.8|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|95828.69||||95828.69|196.54|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|95828.69||||95828.69|31729.6|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95828.69||||95828.69|75499.2|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95828.69||||95828.69|28413.21|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95828.69||||95828.69|31729.6|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95828.69||||95828.69|75499.2|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|95828.69||||95828.69|28413.21|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|95828.69||||95828.69|28413.21|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|95828.69||||95828.69|66121.8|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95828.69||||95828.69|28413.21|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|Self-pay|Self-pay|95828.69||||95828.69|33540.04|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|95828.69||||95828.69|28413.21|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|95828.69||||95828.69|28413.21|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95828.69||||95828.69|47914.35|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|95828.69||||95828.69|31729.6|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|95828.69||||95828.69|31729.6|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95828.69||||95828.69|47914.35|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95828.69||||95828.69|31729.6|75499.2|196.54
108956|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IPILIMUMAB 200 MG/40 ML (5 MG/ML) INTRAVENOUS SOLUTION|40 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|95828.69||||95828.69|63459.2|75499.2|196.54
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|AARP [1000]|AARP [100000]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|AETNA [1015]|AETNA [101529]|6873.76||||6873.76|4967.54|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6873.76||||6873.76|2038.07|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BCBS UTHCT [115568]|6873.76||||6873.76|3230.67|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6873.76||||6873.76|0|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6873.76||||6873.76|3436.88|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6873.76||||6873.76|4330.47|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6873.76||||6873.76|2038.07|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA [1260]|CIGNA GWH [126023]|6873.76||||6873.76|3436.88|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|6873.76||||6873.76|4742.89|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6873.76||||6873.76|2502.38|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6873.76||||6873.76|4967.54|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6873.76||||6873.76|2038.07|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6873.76||||6873.76|4967.54|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6873.76||||6873.76|2038.07|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|6873.76||||6873.76|2038.07|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|6873.76||||6873.76|4742.89|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6873.76||||6873.76|2038.07|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|Self-pay|Self-pay|6873.76||||6873.76|2405.82|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6873.76||||6873.76|2038.07|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6873.76||||6873.76|2038.07|4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6873.76||||6873.76||4967.54|2038.07
10910|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENTOSTATIN 10 MG INTRAVENOUS SOLUTION|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6873.76||||6873.76||4967.54|2038.07
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AARP [1000]|AARP [100000]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AETNA [1015]|AETNA [101529]|306.9||||306.9|135.34|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|306.9||||306.9|91|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BCBS UTHCT [115568]|306.9||||306.9|144.24|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|306.9||||306.9|153.45|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|306.9||||306.9|153.45|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|306.9||||306.9|193.35|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|306.9||||306.9|91|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA GWH [126023]|306.9||||306.9|168.8|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|GROUP PENSION ADMIN [1450]|GPA [145000]|306.9||||306.9|211.76|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|306.9||||306.9|153.45|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|306.9||||306.9|135.34|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|306.9||||306.9|91|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|306.9||||306.9|135.34|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|306.9||||306.9|91|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|306.9||||306.9|91|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|PHCS [1780]|PHCS MULTIPLAN [178000]|306.9||||306.9|211.76|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|306.9||||306.9|91|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|Self-pay|Self-pay|306.9||||306.9|107.41|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|306.9||||306.9|91|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|306.9||||306.9|91|211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|306.9||||306.9||211.76|91
10917|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 5 % TOPICAL CREAM|60 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|306.9||||306.9||211.76|91
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AARP [1000]|AARP [100000]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AETNA [1015]|AETNA [101529]|20.67||||20.67|9.12|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.67||||20.67|6.13|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BCBS UTHCT [115568]|20.67||||20.67|9.71|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.67||||20.67|10.34|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.67||||20.67|10.34|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.67||||20.67|13.02|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.67||||20.67|6.13|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|CIGNA [1260]|CIGNA GWH [126023]|20.67||||20.67|11.37|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|20.67||||20.67|14.26|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.67||||20.67|10.34|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.67||||20.67|9.12|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.67||||20.67|6.13|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.67||||20.67|9.12|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.67||||20.67|6.13|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.67||||20.67|6.13|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|20.67||||20.67|14.26|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.67||||20.67|6.13|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|Self-pay|Self-pay|20.67||||20.67|7.23|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.67||||20.67|6.13|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.67||||20.67|6.13|14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.67||||20.67||14.26|6.13
10918|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PERMETHRIN 1 % TOPICAL LIQUID|59 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.67||||20.67||14.26|6.13
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|41.98||||41.98|18.51|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.98||||41.98|12.45|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|41.98||||41.98|19.73|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.98||||41.98|20.99|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.98||||41.98|20.99|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.98||||41.98|26.45|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.98||||41.98|12.45|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|41.98||||41.98|23.09|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|41.98||||41.98|28.97|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.98||||41.98|20.99|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.98||||41.98|18.51|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.98||||41.98|12.45|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.98||||41.98|18.51|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.98||||41.98|12.45|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.98||||41.98|12.45|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|41.98||||41.98|28.97|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.98||||41.98|12.45|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|Self-pay|Self-pay|41.98||||41.98|14.69|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.98||||41.98|12.45|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.98||||41.98|12.45|28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.98||||41.98||28.97|12.45
109401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 500 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.98||||41.98||28.97|12.45
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|31.02||||31.02|13.68|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.02||||31.02|9.2|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|31.02||||31.02|14.58|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.02||||31.02|15.51|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.02||||31.02|15.51|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.02||||31.02|19.54|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.02||||31.02|9.2|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|31.02||||31.02|17.06|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|31.02||||31.02|21.4|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.02||||31.02|15.51|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.02||||31.02|13.68|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.02||||31.02|9.2|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.02||||31.02|13.68|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.02||||31.02|9.2|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.02||||31.02|9.2|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|31.02||||31.02|21.4|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.02||||31.02|9.2|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|Self-pay|Self-pay|31.02||||31.02|10.86|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.02||||31.02|9.2|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.02||||31.02|9.2|21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.02||||31.02||21.4|9.2
109403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VILAZODONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.02||||31.02||21.4|9.2
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|AARP [1000]|AARP [100000]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|AETNA [1015]|AETNA [101529]|30.91||||30.91|13.63|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.91||||30.91|9.16|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|BCBS [1155]|BCBS UTHCT [115568]|30.91||||30.91|14.53|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.91||||30.91|15.46|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.91||||30.91|15.46|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.91||||30.91|19.47|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.91||||30.91|9.16|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|CIGNA [1260]|CIGNA GWH [126023]|30.91||||30.91|17|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|30.91||||30.91|21.33|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.91||||30.91|15.46|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.91||||30.91|13.63|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.91||||30.91|9.16|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.91||||30.91|13.63|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.91||||30.91|9.16|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.91||||30.91|9.16|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|30.91||||30.91|21.33|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.91||||30.91|9.16|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|Self-pay|Self-pay|30.91||||30.91|10.82|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.91||||30.91|9.16|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.91||||30.91|9.16|21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.91||||30.91||21.33|9.16
10941|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 0.6 % ORAL MUCOSAL LIQUID|178 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.91||||30.91||21.33|9.16
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|AARP [1000]|AARP [100000]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|AETNA [1015]|AETNA [101529]|210||||210|0|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|210||||210|62.27|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BCBS UTHCT [115568]|210||||210|98.7|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|210||||210|0|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|210||||210|105|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|210||||210|132.3|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|210||||210|62.27|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|CIGNA [1260]|CIGNA GWH [126023]|210||||210|115.5|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|210||||210|144.9|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|210||||210|105|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|210||||210|0|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|210||||210|62.27|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|210||||210|0|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|210||||210|62.27|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|210||||210|62.27|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|210||||210|144.9|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|210||||210|62.27|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|Self-pay|Self-pay|210||||210|73.5|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|210||||210|62.27|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|210||||210|62.27|144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|210||||210||144.9|62.27
109481|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PENTETATE (DTPA) PER DOSE UP TO 25MCI|25 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|210||||210||144.9|62.27
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|AARP [1000]|AARP [100000]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|AETNA [1015]|AETNA [101529]|632.4||||632.4|278.89|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|632.4||||632.4|187.51|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|BCBS [1155]|BCBS UTHCT [115568]|632.4||||632.4|297.23|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|632.4||||632.4|316.2|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|632.4||||632.4|316.2|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|632.4||||632.4|398.41|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|632.4||||632.4|187.51|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|CIGNA [1260]|CIGNA GWH [126023]|632.4||||632.4|347.82|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|GROUP PENSION ADMIN [1450]|GPA [145000]|632.4||||632.4|436.36|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|HEALTHFIRST [2395]|HEALTHFIRST [239500]|632.4||||632.4|316.2|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|MAILHANDLERS [1595]|MAILHANDLERS [159500]|632.4||||632.4|278.89|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|632.4||||632.4|187.51|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|632.4||||632.4|278.89|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|632.4||||632.4|187.51|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|PENDING SSI [1616]|PENDING SSI RCA [161601]|632.4||||632.4|187.51|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|PHCS [1780]|PHCS MULTIPLAN [178000]|632.4||||632.4|436.36|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|632.4||||632.4|187.51|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|Self-pay|Self-pay|632.4||||632.4|221.34|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|632.4||||632.4|187.51|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|632.4||||632.4|187.51|436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|UMR [2035]|UMR UNITED HEALTHCARE [203502]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|632.4||||632.4||436.36|187.51
109784|ERX|0250 - PHARMACY-GENERAL|SODIUM NITRITE-SODIUM THIOSULFATE 300 MG/10 ML-12.5 GRAM/50 ML IV SOLN|60 kit|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|632.4||||632.4||436.36|187.51
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AARP [1000]|AARP [100000]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AETNA [1015]|AETNA [101529]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS [1155]|BCBS UTHCT [115568]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|CIGNA [1260]|CIGNA GWH [126023]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|Self-pay|Self-pay|2100||||2100|735|735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2100||||2100||735|735
11000000|EAP|0110 - ROOM & BOARD-PRIVATE (ONE BED)-GENERAL|HC PRIVATE ROOM GENERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2100||||2100||735|735
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.65||||4.65|2.05|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.65||||4.65|1.38|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.65||||4.65|2.19|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.65||||4.65|2.33|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.65||||4.65|2.33|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.65||||4.65|2.93|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.65||||4.65|1.38|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.65||||4.65|2.56|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.65||||4.65|3.21|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.65||||4.65|2.33|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.65||||4.65|2.05|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.65||||4.65|1.38|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.65||||4.65|2.05|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.65||||4.65|1.38|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.65||||4.65|1.38|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.65||||4.65|3.21|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.65||||4.65|1.38|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|4.65||||4.65|1.63|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.65||||4.65|1.38|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.65||||4.65|1.38|3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.65||||4.65||3.21|1.38
11018|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 50 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.65||||4.65||3.21|1.38
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.82||||3.82|1.68|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.82||||3.82|1.13|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|3.82||||3.82|1.8|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.82||||3.82|1.91|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.82||||3.82|1.91|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.82||||3.82|2.41|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.82||||3.82|1.13|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|3.82||||3.82|2.1|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.82||||3.82|2.64|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.82||||3.82|1.91|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.82||||3.82|1.68|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.82||||3.82|1.13|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.82||||3.82|1.68|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.82||||3.82|1.13|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.82||||3.82|1.13|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.82||||3.82|2.64|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.82||||3.82|1.13|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|Self-pay|Self-pay|3.82||||3.82|1.34|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.82||||3.82|1.13|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.82||||3.82|1.13|2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.82||||3.82||2.64|1.13
11019|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 30 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.82||||3.82||2.64|1.13
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AARP [1000]|AARP [100000]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AETNA [1015]|AETNA [101529]|30.06||||30.06|19.49|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.06||||30.06|8.91|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BCBS UTHCT [115568]|30.06||||30.06|14.13|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.06||||30.06|0|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.06||||30.06|15.03|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.06||||30.06|18.94|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.06||||30.06|8.91|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA GWH [126023]|30.06||||30.06|16.53|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|30.06||||30.06|20.74|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.06||||30.06|4.83|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.06||||30.06|19.49|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.06||||30.06|8.91|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.06||||30.06|19.49|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.06||||30.06|8.91|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.06||||30.06|8.91|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|30.06||||30.06|20.74|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.06||||30.06|8.91|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|Self-pay|Self-pay|30.06||||30.06|10.52|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.06||||30.06|8.91|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.06||||30.06|8.91|20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.06||||30.06||20.74|4.83
11023|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHYTONADIONE (VITAMIN K1) 10 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.06||||30.06||20.74|4.83
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AARP [1000]|AARP [100000]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AETNA [1015]|AETNA [101529]|50.9||||50.9|22.45|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.9||||50.9|15.09|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BCBS UTHCT [115568]|50.9||||50.9|23.92|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.9||||50.9|25.45|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.9||||50.9|25.45|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.9||||50.9|32.07|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.9||||50.9|15.09|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|CIGNA [1260]|CIGNA GWH [126023]|50.9||||50.9|28|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|50.9||||50.9|35.12|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50.9||||50.9|25.45|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.9||||50.9|22.45|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.9||||50.9|15.09|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.9||||50.9|22.45|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.9||||50.9|15.09|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|50.9||||50.9|15.09|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|50.9||||50.9|35.12|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.9||||50.9|15.09|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|Self-pay|Self-pay|50.9||||50.9|17.81|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50.9||||50.9|15.09|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.9||||50.9|15.09|35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.9||||50.9||35.12|15.09
110250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 10 MG TABLET|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.9||||50.9||35.12|15.09
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|AARP [1000]|AARP [100000]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|AETNA [1015]|AETNA [101529]|107.57||||107.57|4.56|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|107.57||||107.57|31.89|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|BCBS [1155]|BCBS UTHCT [115568]|107.57||||107.57|50.56|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|107.57||||107.57|0|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|107.57||||107.57|53.79|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|107.57||||107.57|67.77|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|107.57||||107.57|31.89|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|CIGNA [1260]|CIGNA GWH [126023]|107.57||||107.57|59.16|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|107.57||||107.57|74.22|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|107.57||||107.57|53.79|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|107.57||||107.57|4.56|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|107.57||||107.57|31.89|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|107.57||||107.57|4.56|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|107.57||||107.57|31.89|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|107.57||||107.57|31.89|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|107.57||||107.57|74.22|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|107.57||||107.57|31.89|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|Self-pay|Self-pay|107.57||||107.57|37.65|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|107.57||||107.57|31.89|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|107.57||||107.57|31.89|74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|107.57||||107.57||74.22|4.56
110257|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|107.57||||107.57||74.22|4.56
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|AARP [1000]|AARP [100000]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|AETNA [1015]|AETNA [101529]|143.22||||143.22|63.16|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|143.22||||143.22|42.46|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|BCBS [1155]|BCBS UTHCT [115568]|143.22||||143.22|67.31|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|143.22||||143.22|71.61|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|143.22||||143.22|71.61|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|143.22||||143.22|90.23|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|143.22||||143.22|42.46|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|CIGNA [1260]|CIGNA GWH [126023]|143.22||||143.22|78.77|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|143.22||||143.22|98.82|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|143.22||||143.22|71.61|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|143.22||||143.22|63.16|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|143.22||||143.22|42.46|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|143.22||||143.22|63.16|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|143.22||||143.22|42.46|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|143.22||||143.22|42.46|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|143.22||||143.22|98.82|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|143.22||||143.22|42.46|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|Self-pay|Self-pay|143.22||||143.22|50.13|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|143.22||||143.22|42.46|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|143.22||||143.22|42.46|98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|143.22||||143.22||98.82|42.46
110258|ERX|0250 - PHARMACY-GENERAL|AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|143.22||||143.22||98.82|42.46
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|0.15||||0.15|0.07|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.15||||0.15|0.04|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.15||||0.15|0.07|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.15||||0.15|0.08|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.15||||0.15|0.08|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.15||||0.15|0.09|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.15||||0.15|0.04|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.15||||0.15|0.08|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.15||||0.15|0.1|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.15||||0.15|0.08|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.15||||0.15|0.07|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.15||||0.15|0.04|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.15||||0.15|0.07|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.15||||0.15|0.04|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.15||||0.15|0.04|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.15||||0.15|0.1|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.15||||0.15|0.04|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|0.15||||0.15|0.05|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.15||||0.15|0.04|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.15||||0.15|0.04|0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.15||||0.15||0.1|0.04
110305|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 324 MG (65 MG IRON) TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.15||||0.15||0.1|0.04
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|21.34||||21.34|9.41|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.34||||21.34|6.33|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|21.34||||21.34|10.03|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.34||||21.34|10.67|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.34||||21.34|10.67|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.34||||21.34|13.44|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.34||||21.34|6.33|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|21.34||||21.34|11.74|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|21.34||||21.34|14.72|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.34||||21.34|10.67|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.34||||21.34|9.41|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.34||||21.34|6.33|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.34||||21.34|9.41|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.34||||21.34|6.33|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.34||||21.34|6.33|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|21.34||||21.34|14.72|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.34||||21.34|6.33|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|Self-pay|Self-pay|21.34||||21.34|7.47|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.34||||21.34|6.33|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.34||||21.34|6.33|14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.34||||21.34||14.72|6.33
110427|ERX|0250 - PHARMACY-GENERAL|TICAGRELOR 90 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.34||||21.34||14.72|6.33
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|11.16||||11.16|2.3|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.16||||11.16||7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|11.16||||11.16|2.16|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.16||||11.16|3.31|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.16||||11.16||7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.16||||11.16||7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BCBS UTHCT [115568]|11.16||||11.16|5.25|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.16||||11.16|0|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.16||||11.16|5.58|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.16||||11.16|7.03|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.16||||11.16|3.31|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.16||||11.16||7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA GWH [126023]|11.16||||11.16|6.14|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.16||||11.16|7.7|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.16||||11.16|0.2|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.16||||11.16||7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.16||||11.16|2.16|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.16||||11.16|3.31|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.16||||11.16||7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.16||||11.16|2.16|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.16||||11.16|3.31|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.16||||11.16|3.31|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.16||||11.16|7.7|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.16||||11.16|3.31|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|11.16||||11.16|3.91|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.16||||11.16|3.31|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.16||||11.16|3.31|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.16||||11.16|2.3|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.16||||11.16||7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.16||||11.16||7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.16||||11.16|2.3|7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.16||||11.16||7.7|0.2
11074|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 10 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.16||||11.16||7.7|0.2
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|AARP [1000]|AARP [100000]|32875.04||||32875.04|16437.52|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32875.04||||32875.04|842.89|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|AETNA [1015]|AETNA [101529]|32875.04||||32875.04|2964.82|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32875.04||||32875.04|9747.45|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32875.04||||32875.04|834.54|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32875.04||||32875.04|834.54|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|BCBS [1155]|BCBS UTHCT [115568]|32875.04||||32875.04|15451.27|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32875.04||||32875.04|0|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32875.04||||32875.04|16437.52|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32875.04||||32875.04|20711.28|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32875.04||||32875.04|9747.45|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32875.04||||32875.04|834.54|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|CIGNA [1260]|CIGNA GWH [126023]|32875.04||||32875.04|16437.52|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|32875.04||||32875.04|22683.78|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|32875.04||||32875.04|286.16|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32875.04||||32875.04|834.54|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32875.04||||32875.04|2964.82|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32875.04||||32875.04|9747.45|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32875.04||||32875.04|834.54|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32875.04||||32875.04|2964.82|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32875.04||||32875.04|9747.45|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|32875.04||||32875.04|9747.45|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|32875.04||||32875.04|22683.78|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32875.04||||32875.04|9747.45|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|Self-pay|Self-pay|32875.04||||32875.04|11506.26|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|32875.04||||32875.04|9747.45|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32875.04||||32875.04|9747.45|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32875.04||||32875.04|16437.52|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|32875.04||||32875.04|834.54|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32875.04||||32875.04|834.54|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32875.04||||32875.04|16437.52|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32875.04||||32875.04|834.54|22683.78|286.16
110751|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT|45 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32875.04||||32875.04|1669.08|22683.78|286.16
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|5.74||||5.74|2.3|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.74||||5.74||3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|5.74||||5.74|2.16|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.74||||5.74|1.7|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.74||||5.74||3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.74||||5.74||3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BCBS UTHCT [115568]|5.74||||5.74|2.7|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.74||||5.74|0|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.74||||5.74|2.87|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.74||||5.74|3.62|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.74||||5.74|1.7|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.74||||5.74||3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA GWH [126023]|5.74||||5.74|3.16|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.74||||5.74|3.96|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.74||||5.74|0.2|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.74||||5.74||3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.74||||5.74|2.16|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.74||||5.74|1.7|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.74||||5.74||3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.74||||5.74|2.16|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.74||||5.74|1.7|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.74||||5.74|1.7|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.74||||5.74|3.96|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.74||||5.74|1.7|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|5.74||||5.74|2.01|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.74||||5.74|1.7|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.74||||5.74|1.7|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.74||||5.74|2.3|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.74||||5.74||3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.74||||5.74||3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.74||||5.74|2.3|3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.74||||5.74||3.96|0.2
11076|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 20 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.74||||5.74||3.96|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|11.47||||11.47|9.2|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.47||||11.47||9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|11.47||||11.47|8.64|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.47||||11.47|3.4|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.47||||11.47||9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.47||||11.47||9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BCBS UTHCT [115568]|11.47||||11.47|5.39|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.47||||11.47|0|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.47||||11.47|5.74|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.47||||11.47|7.23|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.47||||11.47|3.4|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.47||||11.47||9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA GWH [126023]|11.47||||11.47|6.31|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.47||||11.47|7.91|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.47||||11.47|0.2|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.47||||11.47||9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.47||||11.47|8.64|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.47||||11.47|3.4|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.47||||11.47||9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.47||||11.47|8.64|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.47||||11.47|3.4|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.47||||11.47|3.4|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.47||||11.47|7.91|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.47||||11.47|3.4|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|11.47||||11.47|4.01|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.47||||11.47|3.4|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.47||||11.47|3.4|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.47||||11.47|9.2|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.47||||11.47||9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.47||||11.47||9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.47||||11.47|9.2|9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.47||||11.47||9.2|0.2
11079|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 40 MEQ/100ML IN STERILE WATER INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.47||||11.47||9.2|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AARP [1000]|AARP [100000]|27.9||||27.9|12.56|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.9||||27.9||19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AETNA [1015]|AETNA [101529]|27.9||||27.9|4.32|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.9||||27.9|8.27|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.9||||27.9||19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.9||||27.9||19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|27.9||||27.9|13.11|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.9||||27.9|0|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.9||||27.9|13.95|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.9||||27.9|17.58|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.9||||27.9|8.27|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.9||||27.9||19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|27.9||||27.9|15.35|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.9||||27.9|19.25|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.9||||27.9|0.2|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.9||||27.9||19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.9||||27.9|4.32|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.9||||27.9|8.27|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.9||||27.9||19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.9||||27.9|4.32|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.9||||27.9|8.27|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.9||||27.9|8.27|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.9||||27.9|19.25|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.9||||27.9|8.27|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|Self-pay|Self-pay|27.9||||27.9|9.76|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.9||||27.9|8.27|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.9||||27.9|8.27|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.9||||27.9|12.56|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.9||||27.9||19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.9||||27.9||19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.9||||27.9|12.56|19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.9||||27.9||19.25|0.2
11081|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.9||||27.9||19.25|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AARP [1000]|AARP [100000]|31||||31|13.95|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31||21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AETNA [1015]|AETNA [101529]|31||||31|8.64|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|9.19|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31||21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31||21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|0|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|9.19|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31||21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|31||||31|17.05|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|0.2|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31||21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|8.64|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|9.19|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31||21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|8.64|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|9.19|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|9.19|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|9.19|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|Self-pay|Self-pay|31||||31|10.85|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|9.19|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|9.19|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31|13.95|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31||21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31||21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31|13.95|21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31||21.39|0.2
11082|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 40 MEQ/L IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31||21.39|0.2
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|6.64||||6.64|2.93|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.64||||6.64|1.97|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|6.64||||6.64|3.12|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.64||||6.64|3.32|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.64||||6.64|3.32|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.64||||6.64|4.18|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.64||||6.64|1.97|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|6.64||||6.64|3.65|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.64||||6.64|4.58|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.64||||6.64|3.32|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.64||||6.64|2.93|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.64||||6.64|1.97|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.64||||6.64|2.93|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.64||||6.64|1.97|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.64||||6.64|1.97|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.64||||6.64|4.58|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.64||||6.64|1.97|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|6.64||||6.64|2.32|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.64||||6.64|1.97|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.64||||6.64|1.97|4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.64||||6.64||4.58|1.97
11083|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CITRATE ER 10 MEQ (1,080 MG) TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.64||||6.64||4.58|1.97
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|AARP [1000]|AARP [100000]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|AETNA [1015]|AETNA [101529]|98.08||||98.08|43.25|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|98.08||||98.08|29.08|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|BCBS [1155]|BCBS UTHCT [115568]|98.08||||98.08|46.1|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|98.08||||98.08|49.04|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|98.08||||98.08|49.04|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|98.08||||98.08|61.79|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|98.08||||98.08|29.08|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|CIGNA [1260]|CIGNA GWH [126023]|98.08||||98.08|53.94|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|98.08||||98.08|67.68|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|98.08||||98.08|49.04|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|98.08||||98.08|43.25|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|98.08||||98.08|29.08|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|98.08||||98.08|43.25|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|98.08||||98.08|29.08|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|98.08||||98.08|29.08|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|98.08||||98.08|67.68|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|98.08||||98.08|29.08|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|Self-pay|Self-pay|98.08||||98.08|34.33|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|98.08||||98.08|29.08|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|98.08||||98.08|29.08|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|12.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|98.08||||98.08||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AARP [1000]|AARP [100000]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AETNA [1015]|AETNA [101529]|470.77||||470.77|207.61|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|470.77||||470.77|139.58|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BCBS UTHCT [115568]|470.77||||470.77|221.26|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|470.77||||470.77|235.39|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|470.77||||470.77|235.39|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|470.77||||470.77|296.59|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|470.77||||470.77|139.58|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|CIGNA [1260]|CIGNA GWH [126023]|470.77||||470.77|258.92|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|470.77||||470.77|324.83|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|470.77||||470.77|235.39|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|470.77||||470.77|207.61|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|470.77||||470.77|139.58|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|470.77||||470.77|207.61|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|470.77||||470.77|139.58|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|470.77||||470.77|139.58|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|470.77||||470.77|324.83|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|470.77||||470.77|139.58|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|Self-pay|Self-pay|470.77||||470.77|164.77|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|470.77||||470.77|139.58|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|470.77||||470.77|139.58|324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|470.77||||470.77||324.83|29.08
110998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 6 MG/ML ORAL SUSPENSION|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|470.77||||470.77||324.83|29.08
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.08||||2.08|0.92|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.08||||2.08|0.62|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.08||||2.08|0.98|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.08||||2.08|1.04|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.08||||2.08|1.04|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.08||||2.08|1.31|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.08||||2.08|0.62|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.08||||2.08|1.14|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.08||||2.08|1.44|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.08||||2.08|1.04|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.08||||2.08|0.92|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.08||||2.08|0.62|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.08||||2.08|0.92|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.08||||2.08|0.62|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.08||||2.08|0.62|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.08||||2.08|1.44|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.08||||2.08|0.62|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.08||||2.08|0.73|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.08||||2.08|0.62|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.08||||2.08|0.62|1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.08||||2.08||1.44|0.62
11110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.08||||2.08||1.44|0.62
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.19||||2.19|0.97|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.19||||2.19|0.65|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.19||||2.19|1.03|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.19||||2.19|1.1|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.19||||2.19|1.1|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.19||||2.19|1.38|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.19||||2.19|0.65|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.19||||2.19|1.2|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.19||||2.19|1.51|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.19||||2.19|1.1|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.19||||2.19|0.97|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.19||||2.19|0.65|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.19||||2.19|0.97|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.19||||2.19|0.65|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.19||||2.19|0.65|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.19||||2.19|1.51|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.19||||2.19|0.65|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|Self-pay|Self-pay|2.19||||2.19|0.77|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.19||||2.19|0.65|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.19||||2.19|0.65|1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.19||||2.19||1.51|0.65
11111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.19||||2.19||1.51|0.65
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|AARP [1000]|AARP [100000]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|AETNA [1015]|AETNA [101529]|164.43||||164.43|41.47|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|164.43||||164.43|48.75|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|BCBS [1155]|BCBS UTHCT [115568]|164.43||||164.43|77.28|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|164.43||||164.43|0|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|164.43||||164.43|82.22|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|164.43||||164.43|103.59|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|164.43||||164.43|48.75|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|CIGNA [1260]|CIGNA GWH [126023]|164.43||||164.43|90.44|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|164.43||||164.43|113.46|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|164.43||||164.43|0.16|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|164.43||||164.43|41.47|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|164.43||||164.43|48.75|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|164.43||||164.43|41.47|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|164.43||||164.43|48.75|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|164.43||||164.43|48.75|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|164.43||||164.43|113.46|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|164.43||||164.43|48.75|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|Self-pay|Self-pay|164.43||||164.43|57.55|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|164.43||||164.43|48.75|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|164.43||||164.43|48.75|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|240 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|164.43||||164.43||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|AARP [1000]|AARP [100000]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA [1015]|AETNA [101529]|2.81||||2.81|0.86|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.81||||2.81|0.83|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BCBS UTHCT [115568]|2.81||||2.81|1.32|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.81||||2.81|0|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.81||||2.81|1.41|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.81||||2.81|1.77|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.81||||2.81|0.83|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA [1260]|CIGNA GWH [126023]|2.81||||2.81|1.55|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.81||||2.81|1.94|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.81||||2.81|0.16|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.81||||2.81|0.86|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.81||||2.81|0.83|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.81||||2.81|0.86|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.81||||2.81|0.83|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.81||||2.81|0.83|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.81||||2.81|1.94|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.81||||2.81|0.83|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|Self-pay|Self-pay|2.81||||2.81|0.98|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.81||||2.81|0.83|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.81||||2.81|0.83|113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.81||||2.81||113.46|0.16
11117|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE 15 MG/5 ML ORAL SOLUTION REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.81||||2.81||113.46|0.16
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|AARP [1000]|AARP [100000]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|AETNA [1015]|AETNA [101529]|0.47||||0.47|0.21|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.47||||0.47|0.14|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|BCBS [1155]|BCBS UTHCT [115568]|0.47||||0.47|0.22|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.47||||0.47|0.24|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.47||||0.47|0.24|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.47||||0.47|0.3|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.47||||0.47|0.14|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|CIGNA [1260]|CIGNA GWH [126023]|0.47||||0.47|0.26|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|GROUP PENSION ADMIN [1450]|GPA [145000]|0.47||||0.47|0.32|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.47||||0.47|0.24|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.47||||0.47|0.21|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.47||||0.47|0.14|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.47||||0.47|0.21|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.47||||0.47|0.14|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.47||||0.47|0.14|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|PHCS [1780]|PHCS MULTIPLAN [178000]|0.47||||0.47|0.32|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.47||||0.47|0.14|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|Self-pay|Self-pay|0.47||||0.47|0.16|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.47||||0.47|0.14|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.47||||0.47|0.14|0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.47||||0.47||0.32|0.14
111183|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 2.6 MG LOZENGES|1 lozenge|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.47||||0.47||0.32|0.14
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|AARP [1000]|AARP [100000]|4627.37||||4627.37|1497|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4627.37||||4627.37|898.72|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|4627.37||||4627.37|2017.44|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4627.37||||4627.37|1372.02|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4627.37||||4627.37|889.82|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4627.37||||4627.37|889.82|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|4627.37||||4627.37|2174.86|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4627.37||||4627.37|0|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4627.37||||4627.37|2313.69|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4627.37||||4627.37|2915.24|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4627.37||||4627.37|1372.02|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4627.37||||4627.37|889.82|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|4627.37||||4627.37|2313.69|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4627.37||||4627.37|3192.89|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4627.37||||4627.37|54.54|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4627.37||||4627.37|889.82|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4627.37||||4627.37|2017.44|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4627.37||||4627.37|1372.02|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4627.37||||4627.37|889.82|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4627.37||||4627.37|2017.44|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4627.37||||4627.37|1372.02|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4627.37||||4627.37|1372.02|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4627.37||||4627.37|3192.89|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4627.37||||4627.37|1372.02|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|Self-pay|Self-pay|4627.37||||4627.37|1619.58|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4627.37||||4627.37|1372.02|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4627.37||||4627.37|1372.02|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4627.37||||4627.37|1497|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4627.37||||4627.37|889.82|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4627.37||||4627.37|889.82|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4627.37||||4627.37|1497|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4627.37||||4627.37|889.82|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4627.37||||4627.37|1779.64|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|AARP [1000]|AARP [100000]|9254.74||||9254.74|4627.37|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9254.74||||9254.74|1797.44|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|AETNA [1015]|AETNA [101529]|9254.74||||9254.74|4034.88|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9254.74||||9254.74|2744.03|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9254.74||||9254.74|1779.64|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9254.74||||9254.74|1779.64|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|BCBS [1155]|BCBS UTHCT [115568]|9254.74||||9254.74|4349.73|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9254.74||||9254.74|0|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9254.74||||9254.74|4627.37|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9254.74||||9254.74|5830.49|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9254.74||||9254.74|2744.03|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9254.74||||9254.74|1779.64|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|CIGNA [1260]|CIGNA GWH [126023]|9254.74||||9254.74|4627.37|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9254.74||||9254.74|6385.77|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9254.74||||9254.74|54.54|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9254.74||||9254.74|1779.64|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9254.74||||9254.74|4034.88|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9254.74||||9254.74|2744.03|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9254.74||||9254.74|1779.64|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9254.74||||9254.74|4034.88|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9254.74||||9254.74|2744.03|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9254.74||||9254.74|2744.03|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9254.74||||9254.74|6385.77|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9254.74||||9254.74|2744.03|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|Self-pay|Self-pay|9254.74||||9254.74|3239.16|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9254.74||||9254.74|2744.03|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9254.74||||9254.74|2744.03|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9254.74||||9254.74|4627.37|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9254.74||||9254.74|1779.64|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9254.74||||9254.74|1779.64|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9254.74||||9254.74|4627.37|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9254.74||||9254.74|1779.64|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9254.74||||9254.74|3559.28|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|AARP [1000]|AARP [100000]|2313.69||||2313.69|748.5|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2313.69||||2313.69|449.36|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|2313.69||||2313.69|1008.72|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2313.69||||2313.69|686.01|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2313.69||||2313.69|444.91|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2313.69||||2313.69|444.91|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|2313.69||||2313.69|1087.43|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2313.69||||2313.69|0|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2313.69||||2313.69|1156.85|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2313.69||||2313.69|1457.62|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2313.69||||2313.69|686.01|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2313.69||||2313.69|444.91|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|2313.69||||2313.69|1156.85|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2313.69||||2313.69|1596.45|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2313.69||||2313.69|54.54|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2313.69||||2313.69|444.91|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2313.69||||2313.69|1008.72|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2313.69||||2313.69|686.01|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2313.69||||2313.69|444.91|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2313.69||||2313.69|1008.72|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2313.69||||2313.69|686.01|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2313.69||||2313.69|686.01|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2313.69||||2313.69|1596.45|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2313.69||||2313.69|686.01|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|Self-pay|Self-pay|2313.69||||2313.69|809.79|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2313.69||||2313.69|686.01|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2313.69||||2313.69|686.01|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2313.69||||2313.69|748.5|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2313.69||||2313.69|444.91|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2313.69||||2313.69|444.91|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2313.69||||2313.69|748.5|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2313.69||||2313.69|444.91|6385.77|54.54
111197|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMMA (IGG) 10 %-GLY-IGA OVER 50 MCG/ML INJECTION SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2313.69||||2313.69|889.82|6385.77|54.54
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.16||||1.16|0.51|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.16||||1.16|0.34|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.16||||1.16|0.55|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.16||||1.16|0.58|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.16||||1.16|0.58|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.16||||1.16|0.73|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.16||||1.16|0.34|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.16||||1.16|0.64|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.16||||1.16|0.8|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.16||||1.16|0.58|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.16||||1.16|0.51|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.16||||1.16|0.34|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.16||||1.16|0.51|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.16||||1.16|0.34|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.16||||1.16|0.34|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.16||||1.16|0.8|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.16||||1.16|0.34|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.16||||1.16|0.41|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.16||||1.16|0.34|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.16||||1.16|0.34|0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.16||||1.16||0.8|0.34
11129|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.16||||1.16||0.8|0.34
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|AARP [1000]|AARP [100000]|28752.5||||28752.5|10000|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28752.5||||28752.5|9561.42|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA [1015]|AETNA [101529]|28752.5||||28752.5|21103.2|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28752.5||||28752.5|8525.12|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28752.5||||28752.5|9466.75|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28752.5||||28752.5|9466.75|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BCBS UTHCT [115568]|28752.5||||28752.5|13513.68|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28752.5||||28752.5|0|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28752.5||||28752.5|14376.25|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28752.5||||28752.5|18114.08|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28752.5||||28752.5|8525.12|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28752.5||||28752.5|9466.75|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA GWH [126023]|28752.5||||28752.5|14376.25|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|28752.5||||28752.5|19839.23|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|28752.5||||28752.5|227.6|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28752.5||||28752.5|9466.75|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28752.5||||28752.5|21103.2|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28752.5||||28752.5|8525.12|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28752.5||||28752.5|9466.75|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28752.5||||28752.5|21103.2|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28752.5||||28752.5|8525.12|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|28752.5||||28752.5|8525.12|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|28752.5||||28752.5|19839.23|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28752.5||||28752.5|8525.12|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|Self-pay|Self-pay|28752.5||||28752.5|10063.37|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|28752.5||||28752.5|8525.12|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28752.5||||28752.5|8525.12|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28752.5||||28752.5|10000|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|28752.5||||28752.5|9466.75|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|28752.5||||28752.5|9466.75|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28752.5||||28752.5|10000|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28752.5||||28752.5|9466.75|21103.2|227.6
111348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BRENTUXIMAB VEDOTIN 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28752.5||||28752.5|18933.5|21103.2|227.6
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|27.02||||27.02|11.92|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.02||||27.02|8.01|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|27.02||||27.02|12.7|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.02||||27.02|13.51|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.02||||27.02|13.51|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.02||||27.02|17.02|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.02||||27.02|8.01|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|27.02||||27.02|14.86|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|27.02||||27.02|18.64|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.02||||27.02|13.51|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.02||||27.02|11.92|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.02||||27.02|8.01|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.02||||27.02|11.92|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.02||||27.02|8.01|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.02||||27.02|8.01|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|27.02||||27.02|18.64|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.02||||27.02|8.01|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|27.02||||27.02|9.46|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.02||||27.02|8.01|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.02||||27.02|8.01|18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.02||||27.02||18.64|8.01
11138|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.02||||27.02||18.64|8.01
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|30.22||||30.22|13.33|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.22||||30.22|8.96|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|30.22||||30.22|14.2|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.22||||30.22|15.11|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.22||||30.22|15.11|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.22||||30.22|19.04|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.22||||30.22|8.96|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|30.22||||30.22|16.62|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|30.22||||30.22|20.85|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.22||||30.22|15.11|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.22||||30.22|13.33|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.22||||30.22|8.96|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.22||||30.22|13.33|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.22||||30.22|8.96|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.22||||30.22|8.96|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|30.22||||30.22|20.85|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.22||||30.22|8.96|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|30.22||||30.22|10.58|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.22||||30.22|8.96|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.22||||30.22|8.96|20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.22||||30.22||20.85|8.96
11144|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.22||||30.22||20.85|8.96
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.85||||0.85|0.37|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.85||||0.85|0.25|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.85||||0.85|0.4|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.85||||0.85|0.43|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.85||||0.85|0.43|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.85||||0.85|0.54|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.85||||0.85|0.25|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.85||||0.85|0.47|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.85||||0.85|0.59|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.85||||0.85|0.43|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.85||||0.85|0.37|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.85||||0.85|0.25|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.85||||0.85|0.37|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.85||||0.85|0.25|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.85||||0.85|0.25|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.85||||0.85|0.59|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.85||||0.85|0.25|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|Self-pay|Self-pay|0.85||||0.85|0.3|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.85||||0.85|0.25|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.85||||0.85|0.25|0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.85||||0.85||0.59|0.25
11146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.85||||0.85||0.59|0.25
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|558||||558|404.48|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|558||||558||404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|558||||558|109.34|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|558||||558|165.45|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|558||||558||404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|558||||558||404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BCBS UTHCT [115568]|558||||558|262.26|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|558||||558|0|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|558||||558|279|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|558||||558|351.54|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|558||||558|165.45|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|558||||558||404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA GWH [126023]|558||||558|279|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|558||||558|385.02|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|558||||558|12.88|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|558||||558||404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|558||||558|109.34|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|558||||558|165.45|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|558||||558||404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|558||||558|109.34|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|558||||558|165.45|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|558||||558|165.45|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|558||||558|385.02|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|558||||558|165.45|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|558||||558|195.3|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|558||||558|165.45|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|558||||558|165.45|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|558||||558|404.48|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|558||||558||404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|558||||558||404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|558||||558|404.48|404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|558||||558||404.48|12.88
111464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/100 ML-MANNITOL-0.9 % NACL INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|558||||558||404.48|12.88
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AARP [1000]|AARP [100000]|66.34||||66.34|27|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AETNA [1015]|AETNA [101529]|66.34||||66.34|26.4|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66.34||||66.34|19.67|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|66.34||||66.34|31.18|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66.34||||66.34|0|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66.34||||66.34|33.17|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66.34||||66.34|41.79|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66.34||||66.34|19.67|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|66.34||||66.34|36.49|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66.34||||66.34|45.77|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66.34||||66.34|0.15|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.34||||66.34|26.4|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66.34||||66.34|19.67|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66.34||||66.34|26.4|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66.34||||66.34|19.67|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|66.34||||66.34|19.67|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66.34||||66.34|45.77|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66.34||||66.34|19.67|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|Self-pay|Self-pay|66.34||||66.34|23.22|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66.34||||66.34|19.67|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66.34||||66.34|19.67|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66.34||||66.34|27|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66.34||||66.34|27|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66.34||||66.34||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AARP [1000]|AARP [100000]|7.44||||7.44|5.4|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.44||||7.44||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AETNA [1015]|AETNA [101529]|7.44||||7.44|5.28|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.44||||7.44|2.21|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.44||||7.44||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.44||||7.44||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|7.44||||7.44|3.5|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.44||||7.44|0|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.44||||7.44|3.72|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.44||||7.44|4.69|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.44||||7.44|2.21|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.44||||7.44||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|7.44||||7.44|4.09|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.44||||7.44|5.13|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.44||||7.44|0.15|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.44||||7.44||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.44||||7.44|5.28|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.44||||7.44|2.21|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.44||||7.44||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.44||||7.44|5.28|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.44||||7.44|2.21|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.44||||7.44|2.21|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.44||||7.44|5.13|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.44||||7.44|2.21|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|Self-pay|Self-pay|7.44||||7.44|2.6|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.44||||7.44|2.21|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.44||||7.44|2.21|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.44||||7.44|5.4|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.44||||7.44||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.44||||7.44||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.44||||7.44|5.4|45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.44||||7.44||45.77|0.15
11150|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL 10 MG/ML INTRAVENOUS EMULSION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.44||||7.44||45.77|0.15
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.81||||0.81|0.36|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.81||||0.81|0.24|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.81||||0.81|0.38|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.81||||0.81|0.41|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.81||||0.81|0.41|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.81||||0.81|0.51|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.81||||0.81|0.24|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.81||||0.81|0.45|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.81||||0.81|0.56|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.81||||0.81|0.41|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.81||||0.81|0.36|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.81||||0.81|0.24|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.81||||0.81|0.36|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.81||||0.81|0.24|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.81||||0.81|0.24|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.81||||0.81|0.56|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.81||||0.81|0.24|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|Self-pay|Self-pay|0.81||||0.81|0.28|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.81||||0.81|0.24|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.81||||0.81|0.24|0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.81||||0.81||0.56|0.24
112|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.81||||0.81||0.56|0.24
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|1.15||||1.15|0.51|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.15||||1.15|0.34|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BCBS UTHCT [115568]|1.15||||1.15|0.54|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.15||||1.15|0.58|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.15||||1.15|0.58|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.15||||1.15|0.72|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.15||||1.15|0.34|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA GWH [126023]|1.15||||1.15|0.63|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.15||||1.15|0.79|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.15||||1.15|0.58|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.15||||1.15|0.51|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.15||||1.15|0.34|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.15||||1.15|0.51|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.15||||1.15|0.34|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.15||||1.15|0.34|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.15||||1.15|0.79|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.15||||1.15|0.34|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|1.15||||1.15|0.4|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.15||||1.15|0.34|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.15||||1.15|0.34|0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.15||||1.15||0.79|0.34
11218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSYLLIUM HUSK (ASPARTAME) 3.4 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.15||||1.15||0.79|0.34
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|AARP [1000]|AARP [100000]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|AETNA [1015]|AETNA [101529]|14.27||||14.27|6.29|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.27||||14.27|4.23|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|BCBS [1155]|BCBS UTHCT [115568]|14.27||||14.27|6.71|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.27||||14.27|7.14|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.27||||14.27|7.14|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.27||||14.27|8.99|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.27||||14.27|4.23|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|CIGNA [1260]|CIGNA GWH [126023]|14.27||||14.27|7.85|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.27||||14.27|9.85|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.27||||14.27|7.14|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.27||||14.27|6.29|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.27||||14.27|4.23|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.27||||14.27|6.29|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.27||||14.27|4.23|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.27||||14.27|4.23|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.27||||14.27|9.85|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.27||||14.27|4.23|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|Self-pay|Self-pay|14.27||||14.27|4.99|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.27||||14.27|4.23|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.27||||14.27|4.23|9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.27||||14.27||9.85|4.23
11236|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRETHRINS-PIPERONYL BUTOXIDE 0.33 %-4 % SHAMPOO|118 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.27||||14.27||9.85|4.23
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.17||||3.17|1.4|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.17||||3.17|0.94|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.17||||3.17|1.49|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.17||||3.17|1.59|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.17||||3.17|1.59|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.17||||3.17|2|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.17||||3.17|0.94|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.17||||3.17|1.74|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.17||||3.17|2.19|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.17||||3.17|1.59|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.17||||3.17|1.4|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.17||||3.17|0.94|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.17||||3.17|1.4|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.17||||3.17|0.94|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.17||||3.17|0.94|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.17||||3.17|2.19|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.17||||3.17|0.94|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|Self-pay|Self-pay|3.17||||3.17|1.11|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.17||||3.17|0.94|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.17||||3.17|0.94|2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.17||||3.17||2.19|0.94
11239|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOSTIGMINE BROMIDE 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.17||||3.17||2.19|0.94
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|AARP [1000]|AARP [100000]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|10550.05||||10550.05|4652.57|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10550.05||||10550.05|3128.09|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|10550.05||||10550.05|4958.52|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10550.05||||10550.05|0|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10550.05||||10550.05|5275.03|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10550.05||||10550.05|6646.53|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10550.05||||10550.05|3128.09|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|10550.05||||10550.05|5275.03|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10550.05||||10550.05|7279.53|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10550.05||||10550.05|5275.03|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10550.05||||10550.05|4652.57|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10550.05||||10550.05|3128.09|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10550.05||||10550.05|4652.57|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10550.05||||10550.05|3128.09|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10550.05||||10550.05|3128.09|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10550.05||||10550.05|7279.53|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10550.05||||10550.05|3128.09|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|Self-pay|Self-pay|10550.05||||10550.05|3692.52|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10550.05||||10550.05|3128.09|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10550.05||||10550.05|3128.09|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10550.05||||10550.05||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|AARP [1000]|AARP [100000]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|2311.43||||2311.43|1019.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2311.43||||2311.43|685.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|2311.43||||2311.43|1086.37|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2311.43||||2311.43|0|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2311.43||||2311.43|1155.72|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2311.43||||2311.43|1456.2|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2311.43||||2311.43|685.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|2311.43||||2311.43|1155.72|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2311.43||||2311.43|1594.89|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2311.43||||2311.43|1155.72|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2311.43||||2311.43|1019.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2311.43||||2311.43|685.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2311.43||||2311.43|1019.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2311.43||||2311.43|685.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2311.43||||2311.43|685.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2311.43||||2311.43|1594.89|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2311.43||||2311.43|685.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|Self-pay|Self-pay|2311.43||||2311.43|809|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2311.43||||2311.43|685.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2311.43||||2311.43|685.34|7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2311.43||||2311.43||7279.53|685.34
11256|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES IMMUNE GLOBULIN (PF) 150 UNIT/ML INTRAMUSCULAR SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2311.43||||2311.43||7279.53|685.34
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|AARP [1000]|AARP [100000]|55.61||||55.61|35.54|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|55.61||||55.61||38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|AETNA [1015]|AETNA [101529]|55.61||||55.61|18.62|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55.61||||55.61|16.49|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55.61||||55.61||38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|55.61||||55.61||38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|BCBS [1155]|BCBS UTHCT [115568]|55.61||||55.61|26.14|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|55.61||||55.61|0|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|55.61||||55.61|27.81|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|55.61||||55.61|35.03|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|55.61||||55.61|16.49|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|55.61||||55.61||38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|CIGNA [1260]|CIGNA GWH [126023]|55.61||||55.61|30.59|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|55.61||||55.61|38.37|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|55.61||||55.61|4.96|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|55.61||||55.61||38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55.61||||55.61|18.62|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|55.61||||55.61|16.49|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|55.61||||55.61||38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55.61||||55.61|18.62|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|55.61||||55.61|16.49|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|55.61||||55.61|16.49|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|55.61||||55.61|38.37|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|55.61||||55.61|16.49|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|Self-pay|Self-pay|55.61||||55.61|19.46|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|55.61||||55.61|16.49|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|55.61||||55.61|16.49|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55.61||||55.61|35.54|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|55.61||||55.61||38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|55.61||||55.61||38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|55.61||||55.61|35.54|38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|55.61||||55.61||38.37|4.96
112786|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION|6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|55.61||||55.61||38.37|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|AARP [1000]|AARP [100000]|166.82||||166.82|106.62|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|166.82||||166.82||115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|AETNA [1015]|AETNA [101529]|166.82||||166.82|55.87|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|166.82||||166.82|49.46|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|166.82||||166.82||115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|166.82||||166.82||115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|BCBS [1155]|BCBS UTHCT [115568]|166.82||||166.82|78.41|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|166.82||||166.82|0|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|166.82||||166.82|83.41|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|166.82||||166.82|105.1|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|166.82||||166.82|49.46|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|166.82||||166.82||115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|CIGNA [1260]|CIGNA GWH [126023]|166.82||||166.82|91.75|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|166.82||||166.82|115.11|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|166.82||||166.82|4.96|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|166.82||||166.82||115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|166.82||||166.82|55.87|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|166.82||||166.82|49.46|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|166.82||||166.82||115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|166.82||||166.82|55.87|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|166.82||||166.82|49.46|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|166.82||||166.82|49.46|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|166.82||||166.82|115.11|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|166.82||||166.82|49.46|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|Self-pay|Self-pay|166.82||||166.82|58.39|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|166.82||||166.82|49.46|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|166.82||||166.82|49.46|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|166.82||||166.82|106.62|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|166.82||||166.82||115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|166.82||||166.82||115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|166.82||||166.82|106.62|115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|166.82||||166.82||115.11|4.96
112787|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION|27 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|166.82||||166.82||115.11|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|AARP [1000]|AARP [100000]|280.14||||280.14|195.47|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|280.14||||280.14||195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|AETNA [1015]|AETNA [101529]|280.14||||280.14|102.43|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|280.14||||280.14|83.06|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|280.14||||280.14||195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|280.14||||280.14||195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|BCBS [1155]|BCBS UTHCT [115568]|280.14||||280.14|131.67|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|280.14||||280.14|0|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|280.14||||280.14|140.07|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|280.14||||280.14|176.49|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|280.14||||280.14|83.06|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|280.14||||280.14||195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|CIGNA [1260]|CIGNA GWH [126023]|280.14||||280.14|154.08|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|280.14||||280.14|193.3|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|280.14||||280.14|4.96|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|280.14||||280.14||195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|280.14||||280.14|102.43|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|280.14||||280.14|83.06|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|280.14||||280.14||195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|280.14||||280.14|102.43|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|280.14||||280.14|83.06|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|280.14||||280.14|83.06|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|280.14||||280.14|193.3|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|280.14||||280.14|83.06|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|Self-pay|Self-pay|280.14||||280.14|98.05|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|280.14||||280.14|83.06|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|280.14||||280.14|83.06|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|280.14||||280.14|195.47|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|280.14||||280.14||195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|280.14||||280.14||195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|280.14||||280.14|195.47|195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|280.14||||280.14||195.47|4.96
112788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION|53 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|280.14||||280.14||195.47|4.96
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|50.9||||50.9|22.45|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.9||||50.9|15.09|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|50.9||||50.9|23.92|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.9||||50.9|25.45|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.9||||50.9|25.45|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.9||||50.9|32.07|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.9||||50.9|15.09|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|50.9||||50.9|28|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|50.9||||50.9|35.12|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50.9||||50.9|25.45|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.9||||50.9|22.45|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.9||||50.9|15.09|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.9||||50.9|22.45|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.9||||50.9|15.09|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|50.9||||50.9|15.09|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|50.9||||50.9|35.12|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.9||||50.9|15.09|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|Self-pay|Self-pay|50.9||||50.9|17.81|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50.9||||50.9|15.09|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.9||||50.9|15.09|35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.9||||50.9||35.12|15.09
112834|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|50.9||||50.9|22.45|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.9||||50.9|15.09|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|50.9||||50.9|23.92|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.9||||50.9|25.45|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.9||||50.9|25.45|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.9||||50.9|32.07|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.9||||50.9|15.09|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|50.9||||50.9|28|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|50.9||||50.9|35.12|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50.9||||50.9|25.45|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.9||||50.9|22.45|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.9||||50.9|15.09|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.9||||50.9|22.45|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.9||||50.9|15.09|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|50.9||||50.9|15.09|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|50.9||||50.9|35.12|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.9||||50.9|15.09|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|Self-pay|Self-pay|50.9||||50.9|17.81|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50.9||||50.9|15.09|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.9||||50.9|15.09|35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.9||||50.9||35.12|15.09
112835|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVAROXABAN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.9||||50.9||35.12|15.09
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AARP [1000]|AARP [100000]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AETNA [1015]|AETNA [101529]|474.3||||474.3|209.17|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|474.3||||474.3|140.63|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BCBS UTHCT [115568]|474.3||||474.3|222.92|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|474.3||||474.3|237.15|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|474.3||||474.3|237.15|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|474.3||||474.3|298.81|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|474.3||||474.3|140.63|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|CIGNA [1260]|CIGNA GWH [126023]|474.3||||474.3|260.87|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|474.3||||474.3|327.27|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|474.3||||474.3|237.15|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|474.3||||474.3|209.17|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|474.3||||474.3|140.63|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|474.3||||474.3|209.17|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|474.3||||474.3|140.63|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|474.3||||474.3|140.63|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|474.3||||474.3|327.27|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|474.3||||474.3|140.63|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|Self-pay|Self-pay|474.3||||474.3|166|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|474.3||||474.3|140.63|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|474.3||||474.3|140.63|327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|474.3||||474.3||327.27|140.63
11291|ERX|0250 - PHARMACY-GENERAL|RIFAMPIN 600 MG INTRAVENOUS SOLUTION|600 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|474.3||||474.3||327.27|140.63
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.22||||4.22|1.86|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.22||||4.22|1.25|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|4.22||||4.22|1.98|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.22||||4.22|2.11|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.22||||4.22|2.11|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.22||||4.22|2.66|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.22||||4.22|1.25|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|4.22||||4.22|2.32|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.22||||4.22|2.91|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.22||||4.22|2.11|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.22||||4.22|1.86|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.22||||4.22|1.25|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.22||||4.22|1.86|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.22||||4.22|1.25|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.22||||4.22|1.25|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.22||||4.22|2.91|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.22||||4.22|1.25|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.22||||4.22|1.48|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.22||||4.22|1.25|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.22||||4.22|1.25|2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.22||||4.22||2.91|1.25
11293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIFAMPIN 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.22||||4.22||2.91|1.25
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.82||||10.82|4.77|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.82||||10.82|3.21|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|10.82||||10.82|5.09|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.82||||10.82|5.41|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.82||||10.82|5.41|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.82||||10.82|6.82|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.82||||10.82|3.21|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|10.82||||10.82|5.95|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.82||||10.82|7.47|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.82||||10.82|5.41|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.82||||10.82|4.77|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.82||||10.82|3.21|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.82||||10.82|4.77|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.82||||10.82|3.21|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.82||||10.82|3.21|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.82||||10.82|7.47|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.82||||10.82|3.21|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|Self-pay|Self-pay|10.82||||10.82|3.79|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.82||||10.82|3.21|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.82||||10.82|3.21|7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.82||||10.82||7.47|3.21
113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAZOLAMIDE 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.82||||10.82||7.47|3.21
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AARP [1000]|AARP [100000]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AETNA [1015]|AETNA [101529]|327.3||||327.3|144.34|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|327.3||||327.3|97.04|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS [1155]|BCBS UTHCT [115568]|327.3||||327.3|153.83|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|327.3||||327.3|163.65|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|327.3||||327.3|163.65|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|327.3||||327.3|206.2|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|327.3||||327.3|97.04|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|CIGNA [1260]|CIGNA GWH [126023]|327.3||||327.3|180.02|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|GROUP PENSION ADMIN [1450]|GPA [145000]|327.3||||327.3|225.84|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|327.3||||327.3|163.65|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|327.3||||327.3|144.34|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|327.3||||327.3|97.04|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|327.3||||327.3|144.34|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|327.3||||327.3|97.04|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|PENDING SSI [1616]|PENDING SSI RCA [161601]|327.3||||327.3|97.04|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|PHCS [1780]|PHCS MULTIPLAN [178000]|327.3||||327.3|225.84|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|327.3||||327.3|97.04|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|Self-pay|Self-pay|327.3||||327.3|114.55|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|327.3||||327.3|97.04|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|327.3||||327.3|97.04|225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|327.3||||327.3||225.84|97.04
113060|ERX|0250 - PHARMACY-GENERAL|LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION|100 mcg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|327.3||||327.3||225.84|97.04
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AARP [1000]|AARP [100000]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AETNA [1015]|AETNA [101529]|3.72||||3.72|1.64|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.72||||3.72|1.1|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|3.72||||3.72|1.75|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.72||||3.72|1.86|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.72||||3.72|1.86|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.72||||3.72|2.34|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.72||||3.72|1.1|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|3.72||||3.72|2.05|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.72||||3.72|2.57|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.72||||3.72|1.86|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.72||||3.72|1.64|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.72||||3.72|1.1|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.72||||3.72|1.64|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.72||||3.72|1.1|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.72||||3.72|1.1|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.72||||3.72|2.57|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.72||||3.72|1.1|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|Self-pay|Self-pay|3.72||||3.72|1.3|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.72||||3.72|1.1|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.72||||3.72|1.1|2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.72||||3.72||2.57|1.1
113082|ERX|0250 - PHARMACY-GENERAL|RACEPINEPHRINE 2.25 % SOLUTION FOR NEBULIZATION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.72||||3.72||2.57|1.1
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|AARP [1000]|AARP [100000]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|AETNA [1015]|AETNA [101529]|465.71||||465.71|205.38|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|465.71||||465.71|138.08|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|465.71||||465.71|218.88|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|465.71||||465.71|0|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|465.71||||465.71|232.86|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|465.71||||465.71|293.4|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|465.71||||465.71|138.08|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|465.71||||465.71|256.14|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|465.71||||465.71|321.34|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|465.71||||465.71|232.86|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|465.71||||465.71|205.38|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|465.71||||465.71|138.08|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|465.71||||465.71|205.38|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|465.71||||465.71|138.08|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|465.71||||465.71|138.08|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|465.71||||465.71|321.34|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|465.71||||465.71|138.08|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|Self-pay|Self-pay|465.71||||465.71|163|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|465.71||||465.71|138.08|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|465.71||||465.71|138.08|321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|465.71||||465.71||321.34|138.08
113088|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VARICELLA VIRUS VACCINE LIVE (PF) 1,350 UNIT/0.5 ML SUBCUTANEOUS SUSP|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|465.71||||465.71||321.34|138.08
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|AARP [1000]|AARP [100000]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|AETNA [1015]|AETNA [101529]|9576||||9576|0|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9576||||9576|2839.28|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|BCBS [1155]|BCBS UTHCT [115568]|9576||||9576|4500.72|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9576||||9576|0|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9576||||9576|4788|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9576||||9576|6032.88|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9576||||9576|2839.28|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|CIGNA [1260]|CIGNA GWH [126023]|9576||||9576|5266.8|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|9576||||9576|6607.44|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9576||||9576|4788|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9576||||9576|0|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9576||||9576|2839.28|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9576||||9576|0|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9576||||9576|2839.28|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|9576||||9576|2839.28|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|9576||||9576|6607.44|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9576||||9576|2839.28|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|Self-pay|Self-pay|9576||||9576|3351.6|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9576||||9576|2839.28|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9576||||9576|2839.28|6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9576||||9576||6607.44|2839.28
113146|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 PENTETATE (DTPA) PER 0.5MCI|0.5 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9576||||9576||6607.44|2839.28
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.11||||0.11|0.05|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.11||||0.11|0.03|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.11||||0.11|0.05|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.11||||0.11|0.06|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.11||||0.11|0.06|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.11||||0.11|0.07|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.11||||0.11|0.03|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.11||||0.11|0.06|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.11||||0.11|0.08|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.11||||0.11|0.06|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.11||||0.11|0.05|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.11||||0.11|0.03|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.11||||0.11|0.05|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.11||||0.11|0.03|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.11||||0.11|0.03|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.11||||0.11|0.08|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.11||||0.11|0.03|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|Self-pay|Self-pay|0.11||||0.11|0.04|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.11||||0.11|0.03|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.11||||0.11|0.03|0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.11||||0.11||0.08|0.03
11349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.6 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.11||||0.11||0.08|0.03
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.38||||1.38|0.61|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.38||||1.38|0.41|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.38||||1.38|0.65|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.38||||1.38|0.69|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.38||||1.38|0.69|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.38||||1.38|0.87|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.38||||1.38|0.41|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.38||||1.38|0.76|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.38||||1.38|0.95|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.38||||1.38|0.69|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.38||||1.38|0.61|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.38||||1.38|0.41|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.38||||1.38|0.61|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.38||||1.38|0.41|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.38||||1.38|0.41|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.38||||1.38|0.95|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.38||||1.38|0.41|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|1.38||||1.38|0.48|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.38||||1.38|0.41|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.38||||1.38|0.41|0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.38||||1.38||0.95|0.41
11350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.38||||1.38||0.95|0.41
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.22||||1.22|0.54|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.22||||1.22|0.36|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.22||||1.22|0.57|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.22||||1.22|0.61|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.22||||1.22|0.61|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.22||||1.22|0.77|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.22||||1.22|0.36|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.22||||1.22|0.67|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.22||||1.22|0.84|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.22||||1.22|0.61|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.22||||1.22|0.54|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.22||||1.22|0.36|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.22||||1.22|0.54|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.22||||1.22|0.36|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.22||||1.22|0.36|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.22||||1.22|0.84|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.22||||1.22|0.36|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.22||||1.22|0.43|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.22||||1.22|0.36|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.22||||1.22|0.36|0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.22||||1.22||0.84|0.36
11351|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.22||||1.22||0.84|0.36
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|139.13||||139.13|61.36|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139.13||||139.13|41.25|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|139.13||||139.13|65.39|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139.13||||139.13|69.57|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139.13||||139.13|69.57|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139.13||||139.13|87.65|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139.13||||139.13|41.25|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|139.13||||139.13|76.52|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|139.13||||139.13|96|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|139.13||||139.13|69.57|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139.13||||139.13|61.36|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139.13||||139.13|41.25|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139.13||||139.13|61.36|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139.13||||139.13|41.25|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|139.13||||139.13|41.25|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|139.13||||139.13|96|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139.13||||139.13|41.25|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|Self-pay|Self-pay|139.13||||139.13|48.7|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|139.13||||139.13|41.25|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139.13||||139.13|41.25|96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139.13||||139.13||96|41.25
113587|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139.13||||139.13||96|41.25
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AARP [1000]|AARP [100000]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AETNA [1015]|AETNA [101529]|0.75||||0.75|0.33|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.75||||0.75|0.22|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BCBS UTHCT [115568]|0.75||||0.75|0.35|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.75||||0.75|0.38|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.75||||0.75|0.38|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.75||||0.75|0.47|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.75||||0.75|0.22|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|CIGNA [1260]|CIGNA GWH [126023]|0.75||||0.75|0.41|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|0.75||||0.75|0.52|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.75||||0.75|0.38|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.75||||0.75|0.33|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.75||||0.75|0.22|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.75||||0.75|0.33|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.75||||0.75|0.22|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.75||||0.75|0.22|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|0.75||||0.75|0.52|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.75||||0.75|0.22|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|Self-pay|Self-pay|0.75||||0.75|0.26|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.75||||0.75|0.22|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.75||||0.75|0.22|0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.75||||0.75||0.52|0.22
11359|ERX|0250 - PHARMACY-GENERAL|SILVER NITRATE APPLICATORS 75 %-25 % TOPICAL STICK REPACK|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.75||||0.75||0.52|0.22
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AARP [1000]|AARP [100000]|387.5||||387.5|94.6|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|387.5||||387.5||276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AETNA [1015]|AETNA [101529]|387.5||||387.5|276.72|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|387.5||||387.5|114.89|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|387.5||||387.5||276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|387.5||||387.5||276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|BCBS [1155]|BCBS UTHCT [115568]|387.5||||387.5|182.13|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|387.5||||387.5|0|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|387.5||||387.5|193.75|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|387.5||||387.5|244.13|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|387.5||||387.5|114.89|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|387.5||||387.5||276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|CIGNA [1260]|CIGNA GWH [126023]|387.5||||387.5|213.13|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|GROUP PENSION ADMIN [1450]|GPA [145000]|387.5||||387.5|267.38|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|387.5||||387.5|144.44|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|387.5||||387.5||276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|387.5||||387.5|276.72|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|387.5||||387.5|114.89|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|387.5||||387.5||276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|387.5||||387.5|276.72|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|387.5||||387.5|114.89|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|PENDING SSI [1616]|PENDING SSI RCA [161601]|387.5||||387.5|114.89|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|PHCS [1780]|PHCS MULTIPLAN [178000]|387.5||||387.5|267.38|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|387.5||||387.5|114.89|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|Self-pay|Self-pay|387.5||||387.5|135.62|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|387.5||||387.5|114.89|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|387.5||||387.5|114.89|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|387.5||||387.5|94.6|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|387.5||||387.5||276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|387.5||||387.5||276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|387.5||||387.5|94.6|276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|387.5||||387.5||276.72|94.6
11368|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SINCALIDE 5 MCG SOLUTION FOR INJECTION|5 mcg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|387.5||||387.5||276.72|94.6
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|39.59||||39.59|7.39|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.59||||39.59|11.74|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BCBS UTHCT [115568]|39.59||||39.59|18.61|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.59||||39.59|0|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.59||||39.59|19.8|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.59||||39.59|24.94|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.59||||39.59|11.74|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA GWH [126023]|39.59||||39.59|21.77|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.59||||39.59|27.32|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|39.59||||39.59|1.03|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.59||||39.59|7.39|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.59||||39.59|11.74|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.59||||39.59|7.39|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.59||||39.59|11.74|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|39.59||||39.59|11.74|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.59||||39.59|27.32|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.59||||39.59|11.74|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|39.59||||39.59|13.86|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|39.59||||39.59|11.74|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.59||||39.59|11.74|27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.59||||39.59||27.32|1.03
113850|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/50 ML IN DEXTROSE (ISO-OSMOTIC) INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.59||||39.59||27.32|1.03
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|AARP [1000]|AARP [100000]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|AETNA [1015]|AETNA [101529]|2.48||||2.48|1.09|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.48||||2.48|0.74|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|BCBS [1155]|BCBS UTHCT [115568]|2.48||||2.48|1.17|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.48||||2.48|1.24|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.48||||2.48|1.24|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.48||||2.48|1.56|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.48||||2.48|0.74|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|CIGNA [1260]|CIGNA GWH [126023]|2.48||||2.48|1.36|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|GROUP PENSION ADMIN [1450]|GPA [145000]|2.48||||2.48|1.71|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.48||||2.48|1.24|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.48||||2.48|1.09|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.48||||2.48|0.74|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.48||||2.48|1.09|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.48||||2.48|0.74|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.48||||2.48|0.74|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|PHCS [1780]|PHCS MULTIPLAN [178000]|2.48||||2.48|1.71|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.48||||2.48|0.74|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|Self-pay|Self-pay|2.48||||2.48|0.87|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.48||||2.48|0.74|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.48||||2.48|0.74|1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.48||||2.48||1.71|0.74
11395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 19 GRAM-7 GRAM/118 ML ENEMA|1 enema|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.48||||2.48||1.71|0.74
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|97.65||||97.65|44.64|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97.65||||97.65|28.95|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|97.65||||97.65|45.9|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97.65||||97.65|0|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97.65||||97.65|48.83|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97.65||||97.65|61.52|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97.65||||97.65|28.95|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|97.65||||97.65|53.71|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|97.65||||97.65|67.38|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|97.65||||97.65|29.23|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97.65||||97.65|44.64|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97.65||||97.65|28.95|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97.65||||97.65|44.64|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97.65||||97.65|28.95|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|97.65||||97.65|28.95|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|97.65||||97.65|67.38|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97.65||||97.65|28.95|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|97.65||||97.65|34.18|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|97.65||||97.65|28.95|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97.65||||97.65|28.95|67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97.65||||97.65||67.38|28.95
114|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97.65||||97.65||67.38|28.95
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|AARP [1000]|AARP [100000]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|AETNA [1015]|AETNA [101529]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|BCBS [1155]|BCBS UTHCT [115568]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|CIGNA [1260]|CIGNA GWH [126023]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|Self-pay|Self-pay|1643||||1643|575.05|575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1643||||1643||575.05|575.05
11400000|EAP|0114 - ROOM & BOARD-PRIVATE (ONE BED)-PSYCHIATRIC|HC PRIVATE ROOM PSYCH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1643||||1643||575.05|575.05
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|12.4||||12.4|5.47|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|12.4||||12.4|5.47|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|12.4||||12.4|5.47|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|12.4||||12.4|5.83|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|12.4||||12.4|5.83|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|12.4||||12.4|5.83|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.4||||12.4|6.2|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.4||||12.4|6.2|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.4||||12.4|6.2|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.4||||12.4|6.2|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.4||||12.4|6.2|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.4||||12.4|6.2|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.4||||12.4|7.81|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.4||||12.4|7.81|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.4||||12.4|7.81|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|12.4||||12.4|6.82|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|12.4||||12.4|6.82|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|12.4||||12.4|6.82|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.4||||12.4|8.56|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.4||||12.4|8.56|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.4||||12.4|8.56|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.4||||12.4|6.2|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.4||||12.4|6.2|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.4||||12.4|6.2|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.4||||12.4|5.47|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.4||||12.4|5.47|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.4||||12.4|5.47|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.4||||12.4|5.47|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.4||||12.4|5.47|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.4||||12.4|5.47|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.4||||12.4|8.56|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.4||||12.4|8.56|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.4||||12.4|8.56|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|Self-pay|Self-pay|12.4||||12.4|4.34|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|Self-pay|Self-pay|12.4||||12.4|4.34|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|Self-pay|Self-pay|12.4||||12.4|4.34|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.4||||12.4|3.68|8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.4||||12.4||8.56|3.68
11403|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % IRRIGATION SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.4||||12.4||8.56|3.68
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|47.06||||47.06|20.75|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|47.06||||47.06|13.95|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|47.06||||47.06|22.12|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|47.06||||47.06|23.53|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|47.06||||47.06|23.53|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|47.06||||47.06|29.65|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|47.06||||47.06|13.95|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|47.06||||47.06|25.88|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|47.06||||47.06|32.47|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|47.06||||47.06|23.53|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|47.06||||47.06|20.75|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|47.06||||47.06|13.95|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|47.06||||47.06|20.75|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|47.06||||47.06|13.95|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|47.06||||47.06|13.95|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|47.06||||47.06|32.47|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|47.06||||47.06|13.95|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|Self-pay|Self-pay|47.06||||47.06|16.47|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|47.06||||47.06|13.95|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|47.06||||47.06|13.95|32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|47.06||||47.06||32.47|13.95
11404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 2 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|47.06||||47.06||32.47|13.95
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|AARP [1000]|AARP [100000]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|2.38||||2.38|1.05|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.38||||2.38|0.71|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|2.38||||2.38|1.12|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.38||||2.38|1.19|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.38||||2.38|1.19|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.38||||2.38|1.5|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.38||||2.38|0.71|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|2.38||||2.38|1.31|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.38||||2.38|1.64|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.38||||2.38|1.19|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.38||||2.38|1.05|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.38||||2.38|0.71|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.38||||2.38|1.05|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.38||||2.38|0.71|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.38||||2.38|0.71|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.38||||2.38|1.64|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.38||||2.38|0.71|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|Self-pay|Self-pay|2.38||||2.38|0.83|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.38||||2.38|0.71|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.38||||2.38|0.71|1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.38||||2.38||1.64|0.71
114047|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG/5 ML (1 MG/ML, 5 ML) ORAL SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.38||||2.38||1.64|0.71
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.89||||0.89|0.39|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.89||||0.89|0.26|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.89||||0.89|0.42|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.89||||0.89|0.45|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.89||||0.89|0.45|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.89||||0.89|0.56|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.89||||0.89|0.26|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.89||||0.89|0.49|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.89||||0.89|0.61|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.89||||0.89|0.45|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.89||||0.89|0.39|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.89||||0.89|0.26|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.89||||0.89|0.39|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.89||||0.89|0.26|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.89||||0.89|0.26|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.89||||0.89|0.61|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.89||||0.89|0.26|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|Self-pay|Self-pay|0.89||||0.89|0.31|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.89||||0.89|0.26|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.89||||0.89|0.26|0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.89||||0.89||0.61|0.26
11421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SOTALOL 80 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.89||||0.89||0.61|0.26
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.3||||3.3|1.46|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.3||||3.3|0.98|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.3||||3.3|1.55|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.3||||3.3|1.65|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.3||||3.3|1.65|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.3||||3.3|2.08|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.3||||3.3|0.98|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.3||||3.3|1.82|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.3||||3.3|2.28|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.3||||3.3|1.65|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.3||||3.3|1.46|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.3||||3.3|0.98|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.3||||3.3|1.46|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.3||||3.3|0.98|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.3||||3.3|0.98|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.3||||3.3|2.28|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.3||||3.3|0.98|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|Self-pay|Self-pay|3.3||||3.3|1.15|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.3||||3.3|0.98|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.3||||3.3|0.98|2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.3||||3.3||2.28|0.98
11425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.3||||3.3||2.28|0.98
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|13.95||||13.95|6.15|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.95||||13.95|4.14|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|13.95||||13.95|6.56|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.95||||13.95|6.98|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.95||||13.95|6.98|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.95||||13.95|8.79|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.95||||13.95|4.14|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|13.95||||13.95|7.67|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.95||||13.95|9.63|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.95||||13.95|6.98|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.95||||13.95|6.15|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.95||||13.95|4.14|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.95||||13.95|6.15|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.95||||13.95|4.14|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.95||||13.95|4.14|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.95||||13.95|9.63|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.95||||13.95|4.14|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|13.95||||13.95|4.88|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.95||||13.95|4.14|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.95||||13.95|4.14|9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.95||||13.95||9.63|4.14
11441|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 100 MG/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.95||||13.95||9.63|4.14
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AARP [1000]|AARP [100000]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.68||||0.68|0.3|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.68||||0.68|0.2|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.68||||0.68|0.32|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.68||||0.68|0.34|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.68||||0.68|0.34|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.68||||0.68|0.43|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.68||||0.68|0.2|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.68||||0.68|0.37|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.68||||0.68|0.47|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.68||||0.68|0.34|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.68||||0.68|0.3|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.68||||0.68|0.2|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.68||||0.68|0.3|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.68||||0.68|0.2|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.68||||0.68|0.2|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.68||||0.68|0.47|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.68||||0.68|0.2|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|Self-pay|Self-pay|0.68||||0.68|0.24|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.68||||0.68|0.2|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.68||||0.68|0.2|0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.68||||0.68||0.47|0.2
11442|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUCRALFATE 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.68||||0.68||0.47|0.2
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|10.86||||10.86|4.79|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.86||||10.86|3.22|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|10.86||||10.86|5.1|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.86||||10.86|5.43|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.86||||10.86|5.43|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.86||||10.86|6.84|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.86||||10.86|3.22|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|10.86||||10.86|5.97|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|10.86||||10.86|7.49|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.86||||10.86|5.43|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.86||||10.86|4.79|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.86||||10.86|3.22|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.86||||10.86|4.79|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.86||||10.86|3.22|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.86||||10.86|3.22|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|10.86||||10.86|7.49|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.86||||10.86|3.22|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|10.86||||10.86|3.8|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.86||||10.86|3.22|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.86||||10.86|3.22|7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.86||||10.86||7.49|3.22
11500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TEMAZEPAM 7.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.86||||10.86||7.49|3.22
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|AARP [1000]|AARP [100000]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|AETNA [1015]|AETNA [101529]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|BCBS [1155]|BCBS UTHCT [115568]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|CIGNA [1260]|CIGNA GWH [126023]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|Self-pay|Self-pay|750||||750|262.5|262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|750||||750||262.5|262.5
11500000|EAP|0115 - ROOM & BOARD-PRIVATE (ONE BED)-HOSPICE|HC PRIVATE HOSPICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|750||||750||262.5|262.5
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|12.4||||12.4|3.17|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.4||||12.4|3.68|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|12.4||||12.4|5.83|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.4||||12.4|0|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.4||||12.4|6.2|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.4||||12.4|7.81|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.4||||12.4|3.68|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|12.4||||12.4|6.82|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.4||||12.4|8.56|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.4||||12.4|6.44|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.4||||12.4|3.17|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.4||||12.4|3.68|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.4||||12.4|3.17|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.4||||12.4|3.68|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.4||||12.4|3.68|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.4||||12.4|8.56|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.4||||12.4|3.68|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|Self-pay|Self-pay|12.4||||12.4|4.34|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.4||||12.4|3.68|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.4||||12.4|3.68|8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.4||||12.4||8.56|3.17
11507|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TERBUTALINE 1 MG/ML SUBCUTANEOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.4||||12.4||8.56|3.17
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|9.24||||9.24|4.07|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.24||||9.24|2.74|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|9.24||||9.24|4.34|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.24||||9.24|4.62|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.24||||9.24|4.62|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.24||||9.24|5.82|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.24||||9.24|2.74|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|9.24||||9.24|5.08|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.24||||9.24|6.38|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.24||||9.24|4.62|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.24||||9.24|4.07|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.24||||9.24|2.74|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.24||||9.24|4.07|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.24||||9.24|2.74|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.24||||9.24|2.74|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.24||||9.24|6.38|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.24||||9.24|2.74|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|Self-pay|Self-pay|9.24||||9.24|3.23|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.24||||9.24|2.74|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.24||||9.24|2.74|6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.24||||9.24||6.38|2.74
11561|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.25 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.24||||9.24||6.38|2.74
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|26.94||||26.94|11.88|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.94||||26.94|7.99|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|26.94||||26.94|12.66|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.94||||26.94|13.47|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.94||||26.94|13.47|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.94||||26.94|16.97|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.94||||26.94|7.99|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|26.94||||26.94|14.82|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|26.94||||26.94|18.59|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|26.94||||26.94|13.47|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.94||||26.94|11.88|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.94||||26.94|7.99|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.94||||26.94|11.88|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.94||||26.94|7.99|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|26.94||||26.94|7.99|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|26.94||||26.94|18.59|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.94||||26.94|7.99|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|Self-pay|Self-pay|26.94||||26.94|9.43|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|26.94||||26.94|7.99|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.94||||26.94|7.99|18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.94||||26.94||18.59|7.99
11562|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIMOLOL MALEATE 0.5 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.94||||26.94||18.59|7.99
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|18.6||||18.6|8.2|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.6||||18.6|5.51|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|18.6||||18.6|8.74|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.6||||18.6|9.3|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.6||||18.6|9.3|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.6||||18.6|11.72|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.6||||18.6|5.51|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|18.6||||18.6|10.23|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.6||||18.6|12.83|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.6||||18.6|9.3|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.6||||18.6|8.2|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.6||||18.6|5.51|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.6||||18.6|8.2|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.6||||18.6|5.51|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.6||||18.6|5.51|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.6||||18.6|12.83|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.6||||18.6|5.51|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|18.6||||18.6|6.51|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.6||||18.6|5.51|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.6||||18.6|5.51|12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.6||||18.6||12.83|5.51
11573|ERX|0250 - PHARMACY-GENERAL|TRANEXAMIC ACID 1,000 MG/10 ML (100 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.6||||18.6||12.83|5.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|AARP [1000]|AARP [100000]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|AETNA [1015]|AETNA [101529]|32.09||||32.09|14.15|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32.09||||32.09|9.51|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|BCBS [1155]|BCBS UTHCT [115568]|32.09||||32.09|15.08|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32.09||||32.09|16.05|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32.09||||32.09|16.05|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32.09||||32.09|20.22|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32.09||||32.09|9.51|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|CIGNA [1260]|CIGNA GWH [126023]|32.09||||32.09|17.65|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|32.09||||32.09|22.14|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|32.09||||32.09|16.05|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32.09||||32.09|14.15|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32.09||||32.09|9.51|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32.09||||32.09|14.15|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32.09||||32.09|9.51|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|32.09||||32.09|9.51|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|32.09||||32.09|22.14|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32.09||||32.09|9.51|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|Self-pay|Self-pay|32.09||||32.09|11.23|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|32.09||||32.09|9.51|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32.09||||32.09|9.51|22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32.09||||32.09||22.14|9.51
11596|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYMYXIN B SULFATE 10,000 UNIT-TRIMETHOPRIM 1 MG/ML EYE DROPS|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32.09||||32.09||22.14|9.51
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|18.46||||18.46|8.14|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.46||||18.46|5.47|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|18.46||||18.46|8.68|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.46||||18.46|9.23|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.46||||18.46|9.23|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.46||||18.46|11.63|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.46||||18.46|5.47|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|18.46||||18.46|10.15|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|18.46||||18.46|12.74|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.46||||18.46|9.23|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.46||||18.46|8.14|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.46||||18.46|5.47|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.46||||18.46|8.14|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.46||||18.46|5.47|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.46||||18.46|5.47|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|18.46||||18.46|12.74|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.46||||18.46|5.47|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|Self-pay|Self-pay|18.46||||18.46|6.46|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.46||||18.46|5.47|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.46||||18.46|5.47|12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.46||||18.46||12.74|5.47
11624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|URSODIOL 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.46||||18.46||12.74|5.47
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AARP [1000]|AARP [100000]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AETNA [1015]|AETNA [101529]|16.12||||16.12|7.11|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.12||||16.12|4.78|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BCBS UTHCT [115568]|16.12||||16.12|7.58|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.12||||16.12|8.06|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.12||||16.12|8.06|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.12||||16.12|10.16|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.12||||16.12|4.78|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|CIGNA [1260]|CIGNA GWH [126023]|16.12||||16.12|8.87|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|16.12||||16.12|11.12|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.12||||16.12|8.06|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.12||||16.12|7.11|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.12||||16.12|4.78|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.12||||16.12|7.11|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.12||||16.12|4.78|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.12||||16.12|4.78|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|16.12||||16.12|11.12|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.12||||16.12|4.78|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|Self-pay|Self-pay|16.12||||16.12|5.64|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.12||||16.12|4.78|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.12||||16.12|4.78|11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.12||||16.12||11.12|4.78
11634|ERX|0250 - PHARMACY-GENERAL|VECURONIUM BROMIDE 10 MG INTRAVENOUS SOLUTION|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.12||||16.12||11.12|4.78
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|AARP [1000]|AARP [100000]|17143.48||||17143.48|8571.74|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17143.48||||17143.48|5750.88|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|AETNA [1015]|AETNA [101529]|17143.48||||17143.48|13043.52|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17143.48||||17143.48|5083.04|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17143.48||||17143.48|5693.94|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17143.48||||17143.48|5693.94|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS [1155]|BCBS UTHCT [115568]|17143.48||||17143.48|8057.44|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17143.48||||17143.48|0|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17143.48||||17143.48|8571.74|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17143.48||||17143.48|10800.39|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17143.48||||17143.48|5083.04|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17143.48||||17143.48|5693.94|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|CIGNA [1260]|CIGNA GWH [126023]|17143.48||||17143.48|8571.74|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17143.48||||17143.48|11829|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17143.48||||17143.48|16.24|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17143.48||||17143.48|5693.94|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17143.48||||17143.48|13043.52|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17143.48||||17143.48|5083.04|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17143.48||||17143.48|5693.94|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17143.48||||17143.48|13043.52|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17143.48||||17143.48|5083.04|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17143.48||||17143.48|5083.04|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17143.48||||17143.48|11829|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17143.48||||17143.48|5083.04|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|Self-pay|Self-pay|17143.48||||17143.48|6000.22|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17143.48||||17143.48|5083.04|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17143.48||||17143.48|5083.04|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17143.48||||17143.48|8571.74|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17143.48||||17143.48|5693.94|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17143.48||||17143.48|5693.94|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17143.48||||17143.48|8571.74|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17143.48||||17143.48|5693.94|13043.52|16.24
116596|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION|14 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17143.48||||17143.48|11387.88|13043.52|16.24
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|AARP [1000]|AARP [100000]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|AETNA [1015]|AETNA [101529]|3.46||||3.46|1.53|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.46||||3.46|1.03|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.46||||3.46|1.63|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.46||||3.46|1.73|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.46||||3.46|1.73|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.46||||3.46|2.18|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.46||||3.46|1.03|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.46||||3.46|1.9|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.46||||3.46|2.39|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.46||||3.46|1.73|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.46||||3.46|1.53|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.46||||3.46|1.03|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.46||||3.46|1.53|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.46||||3.46|1.03|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.46||||3.46|1.03|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.46||||3.46|2.39|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.46||||3.46|1.03|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|Self-pay|Self-pay|3.46||||3.46|1.21|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.46||||3.46|1.03|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.46||||3.46|1.03|2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.46||||3.46||2.39|1.03
11664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 1 MG TABLET|3 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.46||||3.46||2.39|1.03
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AARP [1000]|AARP [100000]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AETNA [1015]|AETNA [101529]|10.82||||10.82|4.77|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.82||||10.82|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BCBS UTHCT [115568]|10.82||||10.82|5.09|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.82||||10.82|5.41|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.82||||10.82|5.41|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.82||||10.82|6.82|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.82||||10.82|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|CIGNA [1260]|CIGNA GWH [126023]|10.82||||10.82|5.95|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.82||||10.82|7.47|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.82||||10.82|5.41|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.82||||10.82|4.77|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.82||||10.82|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.82||||10.82|4.77|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.82||||10.82|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.82||||10.82|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.82||||10.82|7.47|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.82||||10.82|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|Self-pay|Self-pay|10.82||||10.82|3.79|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.82||||10.82|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.82||||10.82|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.82||||10.82||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|AARP [1000]|AARP [100000]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|AETNA [1015]|AETNA [101529]|13.33||||13.33|5.88|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.33||||13.33|3.95|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|BCBS [1155]|BCBS UTHCT [115568]|13.33||||13.33|6.27|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.33||||13.33|6.67|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.33||||13.33|6.67|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.33||||13.33|8.4|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.33||||13.33|3.95|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|CIGNA [1260]|CIGNA GWH [126023]|13.33||||13.33|7.33|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.33||||13.33|9.2|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.33||||13.33|6.67|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.33||||13.33|5.88|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.33||||13.33|3.95|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.33||||13.33|5.88|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.33||||13.33|3.95|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.33||||13.33|3.95|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.33||||13.33|9.2|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.33||||13.33|3.95|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|Self-pay|Self-pay|13.33||||13.33|4.67|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.33||||13.33|3.95|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.33||||13.33|3.95|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.33||||13.33||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AARP [1000]|AARP [100000]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AETNA [1015]|AETNA [101529]|4.03||||4.03|1.78|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.03||||4.03|1.19|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BCBS UTHCT [115568]|4.03||||4.03|1.89|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.03||||4.03|2.02|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.03||||4.03|2.02|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.03||||4.03|2.54|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.03||||4.03|1.19|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|CIGNA [1260]|CIGNA GWH [126023]|4.03||||4.03|2.22|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.03||||4.03|2.78|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.03||||4.03|2.02|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.03||||4.03|1.78|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.03||||4.03|1.19|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.03||||4.03|1.78|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.03||||4.03|1.19|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.03||||4.03|1.19|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.03||||4.03|2.78|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.03||||4.03|1.19|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|Self-pay|Self-pay|4.03||||4.03|1.41|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.03||||4.03|1.19|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.03||||4.03|1.19|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.03||||4.03||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|AARP [1000]|AARP [100000]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|AETNA [1015]|AETNA [101529]|7.29||||7.29|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.29||||7.29|2.16|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|BCBS [1155]|BCBS UTHCT [115568]|7.29||||7.29|3.43|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.29||||7.29|3.65|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.29||||7.29|3.65|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.29||||7.29|4.59|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.29||||7.29|2.16|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|CIGNA [1260]|CIGNA GWH [126023]|7.29||||7.29|4.01|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.29||||7.29|5.03|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.29||||7.29|3.65|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.29||||7.29|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.29||||7.29|2.16|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.29||||7.29|3.21|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.29||||7.29|2.16|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.29||||7.29|2.16|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.29||||7.29|5.03|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.29||||7.29|2.16|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|Self-pay|Self-pay|7.29||||7.29|2.55|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.29||||7.29|2.16|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.29||||7.29|2.16|9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.29||||7.29||9.2|1.19
11671|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INJECTION SOLUTION *VIAL*|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.29||||7.29||9.2|1.19
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AARP [1000]|AARP [100000]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AETNA [1015]|AETNA [101529]|1374.89||||1374.89|606.33|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1374.89||||1374.89|407.65|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS [1155]|BCBS UTHCT [115568]|1374.89||||1374.89|646.2|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1374.89||||1374.89|687.45|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1374.89||||1374.89|687.45|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1374.89||||1374.89|866.18|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1374.89||||1374.89|407.65|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|CIGNA [1260]|CIGNA GWH [126023]|1374.89||||1374.89|756.19|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1374.89||||1374.89|948.67|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1374.89||||1374.89|687.45|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1374.89||||1374.89|606.33|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1374.89||||1374.89|407.65|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1374.89||||1374.89|606.33|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1374.89||||1374.89|407.65|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|1374.89||||1374.89|407.65|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1374.89||||1374.89|948.67|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1374.89||||1374.89|407.65|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|Self-pay|Self-pay|1374.89||||1374.89|481.21|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1374.89||||1374.89|407.65|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1374.89||||1374.89|407.65|948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1374.89||||1374.89||948.67|407.65
116728|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM 20 MCG-ALBUTEROL 100 MCG/ACTUATION MIST FOR INHALATION|4 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1374.89||||1374.89||948.67|407.65
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|21.36||||21.36|21.36|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.36||||21.36||21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|21.36||||21.36|21.36|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.36||||21.36|6.33|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.36||||21.36||21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.36||||21.36||21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|21.36||||21.36|10.04|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.36||||21.36|0|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.36||||21.36|10.68|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.36||||21.36|13.46|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.36||||21.36|6.33|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.36||||21.36||21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|21.36||||21.36|11.75|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.36||||21.36|14.74|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.36||||21.36|3.43|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.36||||21.36||21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.36||||21.36|21.36|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.36||||21.36|6.33|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.36||||21.36||21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.36||||21.36|21.36|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.36||||21.36|6.33|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.36||||21.36|6.33|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.36||||21.36|14.74|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.36||||21.36|6.33|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|Self-pay|Self-pay|21.36||||21.36|7.48|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.36||||21.36|6.33|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.36||||21.36|6.33|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.36||||21.36|21.36|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.36||||21.36||21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.36||||21.36||21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.36||||21.36|21.36|21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.36||||21.36||21.36|3.43
116809|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 10 MG/ML INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.36||||21.36||21.36|3.43
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.7||||4.7|2.07|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.7||||4.7|1.39|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|4.7||||4.7|2.21|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.7||||4.7|2.35|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.7||||4.7|2.35|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.7||||4.7|2.96|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.7||||4.7|1.39|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|4.7||||4.7|2.59|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.7||||4.7|3.24|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.7||||4.7|2.35|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.7||||4.7|2.07|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.7||||4.7|1.39|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.7||||4.7|2.07|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.7||||4.7|1.39|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.7||||4.7|1.39|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.7||||4.7|3.24|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.7||||4.7|1.39|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.7||||4.7|1.64|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.7||||4.7|1.39|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.7||||4.7|1.39|3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.7||||4.7||3.24|1.39
11692|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIDOVUDINE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.7||||4.7||3.24|1.39
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|AARP [1000]|AARP [100000]|527||||527|527|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|527||||527||527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|AETNA [1015]|AETNA [101529]|527||||527|334.08|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|527||||527|156.26|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|527||||527||527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|527||||527||527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS [1155]|BCBS UTHCT [115568]|527||||527|247.69|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|527||||527|0|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|527||||527|263.5|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|527||||527|332.01|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|527||||527|156.26|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|527||||527||527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|CIGNA [1260]|CIGNA GWH [126023]|527||||527|263.5|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|527||||527|363.63|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|527||||527|0.9|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|527||||527||527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|527||||527|334.08|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|527||||527|156.26|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|527||||527||527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|527||||527|334.08|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|527||||527|156.26|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|527||||527|156.26|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|527||||527|363.63|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|527||||527|156.26|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|Self-pay|Self-pay|527||||527|184.45|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|527||||527|156.26|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|527||||527|156.26|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|527||||527|527|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|527||||527||527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|527||||527||527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|527||||527|527|527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|527||||527||527|0.9
116947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOCETAXEL 160 MG/8 ML (20 MG/ML) INTRAVENOUS SOLUTION|8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|527||||527||527|0.9
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.27||||0.27|0.12|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.27||||0.27|0.08|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.27||||0.27|0.13|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.27||||0.27|0.14|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.27||||0.27|0.14|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.27||||0.27|0.17|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.27||||0.27|0.08|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.27||||0.27|0.15|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.27||||0.27|0.19|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.27||||0.27|0.14|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.27||||0.27|0.12|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.27||||0.27|0.08|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.27||||0.27|0.12|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.27||||0.27|0.08|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.27||||0.27|0.08|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.27||||0.27|0.19|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.27||||0.27|0.08|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.27||||0.27|0.09|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.27||||0.27|0.08|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.27||||0.27|0.08|0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.27||||0.27||0.19|0.08
11701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZOLPIDEM 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.27||||0.27||0.19|0.08
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|12.16||||12.16|5.11|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.16||||12.16|3.61|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|12.16||||12.16|5.72|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.16||||12.16|0|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.16||||12.16|6.08|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.16||||12.16|7.66|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.16||||12.16|3.61|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|12.16||||12.16|6.69|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.16||||12.16|8.39|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.16||||12.16|2.63|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.16||||12.16|5.11|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.16||||12.16|3.61|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.16||||12.16|5.11|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.16||||12.16|3.61|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.16||||12.16|3.61|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.16||||12.16|8.39|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.16||||12.16|3.61|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|12.16||||12.16|4.26|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.16||||12.16|3.61|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.16||||12.16|3.61|8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.16||||12.16||8.39|2.63
117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.16||||12.16||8.39|2.63
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|AARP [1000]|AARP [100000]|7995.25||||7995.25|3997.63|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7995.25||||7995.25|2490.84|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|7995.25||||7995.25|5611.68|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7995.25||||7995.25|2370.59|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7995.25||||7995.25|2466.18|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7995.25||||7995.25|2466.18|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|7995.25||||7995.25|3757.77|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7995.25||||7995.25|0|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7995.25||||7995.25|3997.63|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7995.25||||7995.25|5037.01|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7995.25||||7995.25|2370.59|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7995.25||||7995.25|2466.18|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|7995.25||||7995.25|3997.63|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7995.25||||7995.25|5516.72|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7995.25||||7995.25|49.19|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7995.25||||7995.25|2466.18|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7995.25||||7995.25|5611.68|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7995.25||||7995.25|2370.59|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7995.25||||7995.25|2466.18|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7995.25||||7995.25|5611.68|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7995.25||||7995.25|2370.59|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7995.25||||7995.25|2370.59|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7995.25||||7995.25|5516.72|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7995.25||||7995.25|2370.59|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|Self-pay|Self-pay|7995.25||||7995.25|2798.34|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7995.25||||7995.25|2370.59|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7995.25||||7995.25|2370.59|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7995.25||||7995.25|3997.63|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7995.25||||7995.25|2466.18|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7995.25||||7995.25|2466.18|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7995.25||||7995.25|3997.63|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7995.25||||7995.25|2466.18|5611.68|49.19
117047|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 60 MG INTRAVENOUS SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7995.25||||7995.25|4932.36|5611.68|49.19
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|207.67||||207.67|91.58|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|207.67||||207.67|61.57|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|207.67||||207.67|97.6|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|207.67||||207.67|103.84|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|207.67||||207.67|103.84|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|207.67||||207.67|130.83|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|207.67||||207.67|61.57|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|207.67||||207.67|114.22|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|207.67||||207.67|143.29|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|207.67||||207.67|103.84|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|207.67||||207.67|91.58|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|207.67||||207.67|61.57|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|207.67||||207.67|91.58|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|207.67||||207.67|61.57|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|207.67||||207.67|61.57|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|207.67||||207.67|143.29|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|207.67||||207.67|61.57|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|Self-pay|Self-pay|207.67||||207.67|72.68|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|207.67||||207.67|61.57|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|207.67||||207.67|61.57|143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|207.67||||207.67||143.29|61.57
117256|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 120 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|207.67||||207.67||143.29|61.57
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|3.83||||3.83|1.69|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.83||||3.83|1.14|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.83||||3.83|1.8|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.83||||3.83|1.92|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.83||||3.83|1.92|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.83||||3.83|2.41|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.83||||3.83|1.14|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.83||||3.83|2.11|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.83||||3.83|2.64|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.83||||3.83|1.92|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.83||||3.83|1.69|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.83||||3.83|1.14|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.83||||3.83|1.69|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.83||||3.83|1.14|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.83||||3.83|1.14|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.83||||3.83|2.64|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.83||||3.83|1.14|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|3.83||||3.83|1.34|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.83||||3.83|1.14|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.83||||3.83|1.14|2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.83||||3.83||2.64|1.14
119007|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 30 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.83||||3.83||2.64|1.14
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|25.79||||25.79|11.37|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.79||||25.79|7.65|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|25.79||||25.79|12.12|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.79||||25.79|12.9|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.79||||25.79|12.9|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.79||||25.79|16.25|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.79||||25.79|7.65|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|25.79||||25.79|14.18|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|25.79||||25.79|17.8|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25.79||||25.79|12.9|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.79||||25.79|11.37|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.79||||25.79|7.65|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.79||||25.79|11.37|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.79||||25.79|7.65|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|25.79||||25.79|7.65|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|25.79||||25.79|17.8|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.79||||25.79|7.65|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|25.79||||25.79|9.03|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25.79||||25.79|7.65|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.79||||25.79|7.65|17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.79||||25.79||17.8|7.65
119040|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.79||||25.79||17.8|7.65
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|44.95||||44.95|19.82|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.95||||44.95|13.33|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|44.95||||44.95|21.13|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.95||||44.95|22.48|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.95||||44.95|22.48|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.95||||44.95|28.32|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.95||||44.95|13.33|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|44.95||||44.95|24.72|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|44.95||||44.95|31.02|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|44.95||||44.95|22.48|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.95||||44.95|19.82|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.95||||44.95|13.33|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.95||||44.95|19.82|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.95||||44.95|13.33|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|44.95||||44.95|13.33|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|44.95||||44.95|31.02|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.95||||44.95|13.33|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|44.95||||44.95|15.73|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|44.95||||44.95|13.33|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.95||||44.95|13.33|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.95||||44.95||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|136.4||||136.4|60.15|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136.4||||136.4|40.44|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|136.4||||136.4|64.11|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136.4||||136.4|68.2|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136.4||||136.4|68.2|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136.4||||136.4|85.93|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136.4||||136.4|40.44|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|136.4||||136.4|75.02|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|136.4||||136.4|94.12|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|136.4||||136.4|68.2|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136.4||||136.4|60.15|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136.4||||136.4|40.44|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136.4||||136.4|60.15|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136.4||||136.4|40.44|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|136.4||||136.4|40.44|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|136.4||||136.4|94.12|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136.4||||136.4|40.44|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|Self-pay|Self-pay|136.4||||136.4|47.74|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|136.4||||136.4|40.44|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136.4||||136.4|40.44|94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136.4||||136.4||94.12|13.33
119135|ERX|0250 - PHARMACY-GENERAL|GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136.4||||136.4||94.12|13.33
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|51.34||||51.34|22.64|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.34||||51.34|15.22|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|51.34||||51.34|24.13|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.34||||51.34|25.67|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.34||||51.34|25.67|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.34||||51.34|32.34|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.34||||51.34|15.22|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|51.34||||51.34|28.24|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|51.34||||51.34|35.42|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|51.34||||51.34|25.67|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.34||||51.34|22.64|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.34||||51.34|15.22|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.34||||51.34|22.64|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.34||||51.34|15.22|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|51.34||||51.34|15.22|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|51.34||||51.34|35.42|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.34||||51.34|15.22|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|51.34||||51.34|17.97|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|51.34||||51.34|15.22|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.34||||51.34|15.22|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.34||||51.34||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|43.4||||43.4|19.14|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|43.4||||43.4|12.87|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|43.4||||43.4|20.4|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|43.4||||43.4|21.7|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|43.4||||43.4|21.7|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|43.4||||43.4|27.34|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|43.4||||43.4|12.87|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|43.4||||43.4|23.87|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|43.4||||43.4|29.95|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|43.4||||43.4|21.7|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|43.4||||43.4|19.14|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|43.4||||43.4|12.87|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|43.4||||43.4|19.14|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|43.4||||43.4|12.87|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|43.4||||43.4|12.87|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|43.4||||43.4|29.95|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|43.4||||43.4|12.87|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|43.4||||43.4|15.19|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|43.4||||43.4|12.87|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|43.4||||43.4|12.87|35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|43.4||||43.4||35.42|12.87
119149|ERX|0250 - PHARMACY-GENERAL|CISATRACURIUM 2 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|43.4||||43.4||35.42|12.87
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|2.08||||2.08|0.92|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.08||||2.08|0.62|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.08||||2.08|0.98|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.08||||2.08|1.04|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.08||||2.08|1.04|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.08||||2.08|1.31|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.08||||2.08|0.62|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.08||||2.08|1.14|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.08||||2.08|1.44|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.08||||2.08|1.04|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.08||||2.08|0.92|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.08||||2.08|0.62|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.08||||2.08|0.92|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.08||||2.08|0.62|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.08||||2.08|0.62|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.08||||2.08|1.44|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.08||||2.08|0.62|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|2.08||||2.08|0.73|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.08||||2.08|0.62|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.08||||2.08|0.62|1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.08||||2.08||1.44|0.62
119246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 15 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.08||||2.08||1.44|0.62
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|14.26||||14.26|6.29|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.26||||14.26|4.23|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|14.26||||14.26|6.7|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.26||||14.26|7.13|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.26||||14.26|7.13|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.26||||14.26|8.98|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.26||||14.26|4.23|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|14.26||||14.26|7.84|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|14.26||||14.26|9.84|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.26||||14.26|7.13|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.26||||14.26|6.29|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.26||||14.26|4.23|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.26||||14.26|6.29|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.26||||14.26|4.23|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.26||||14.26|4.23|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|14.26||||14.26|9.84|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.26||||14.26|4.23|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|14.26||||14.26|4.99|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.26||||14.26|4.23|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.26||||14.26|4.23|9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.26||||14.26||9.84|4.23
119248|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.26||||14.26||9.84|4.23
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|AARP [1000]|AARP [100000]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|AETNA [1015]|AETNA [101529]|45.22||||45.22|19.94|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45.22||||45.22|13.41|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|BCBS [1155]|BCBS UTHCT [115568]|45.22||||45.22|21.25|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45.22||||45.22|22.61|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45.22||||45.22|22.61|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45.22||||45.22|28.49|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45.22||||45.22|13.41|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|CIGNA [1260]|CIGNA GWH [126023]|45.22||||45.22|24.87|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|45.22||||45.22|31.2|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|45.22||||45.22|22.61|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45.22||||45.22|19.94|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45.22||||45.22|13.41|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45.22||||45.22|19.94|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45.22||||45.22|13.41|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|45.22||||45.22|13.41|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|45.22||||45.22|31.2|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45.22||||45.22|13.41|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|Self-pay|Self-pay|45.22||||45.22|15.83|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|45.22||||45.22|13.41|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45.22||||45.22|13.41|31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45.22||||45.22||31.2|13.41
119255|ERX|0250 - PHARMACY-GENERAL|FERRIC SUBSULFATE 0.2 GRAM TO 0.22 GRAM/ML TOPICAL SOLN AND APPLICATOR|8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45.22||||45.22||31.2|13.41
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|AARP [1000]|AARP [100000]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|AETNA [1015]|AETNA [101529]|52.33||||52.33|23.08|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.33||||52.33|15.52|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|52.33||||52.33|24.6|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.33||||52.33|0|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.33||||52.33|26.17|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.33||||52.33|32.97|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.33||||52.33|15.52|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|52.33||||52.33|28.78|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|52.33||||52.33|36.11|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|52.33||||52.33|26.17|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.33||||52.33|23.08|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.33||||52.33|15.52|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.33||||52.33|23.08|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.33||||52.33|15.52|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|52.33||||52.33|15.52|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|52.33||||52.33|36.11|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.33||||52.33|15.52|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|Self-pay|Self-pay|52.33||||52.33|18.32|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|52.33||||52.33|15.52|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.33||||52.33|15.52|36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.33||||52.33||36.11|15.52
11931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HAEMOPHILUS B POLYSACCHARID CONJ-TETANUS TOX(PF) 10 MCG/0.5 ML IM SOLN|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.33||||52.33||36.11|15.52
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|25.79||||25.79|11.37|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.79||||25.79|7.65|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|25.79||||25.79|12.12|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.79||||25.79|12.9|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.79||||25.79|12.9|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.79||||25.79|16.25|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.79||||25.79|7.65|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|25.79||||25.79|14.18|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|25.79||||25.79|17.8|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25.79||||25.79|12.9|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.79||||25.79|11.37|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.79||||25.79|7.65|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.79||||25.79|11.37|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.79||||25.79|7.65|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|25.79||||25.79|7.65|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|25.79||||25.79|17.8|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.79||||25.79|7.65|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|Self-pay|Self-pay|25.79||||25.79|9.03|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25.79||||25.79|7.65|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.79||||25.79|7.65|17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.79||||25.79||17.8|7.65
119614|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|APIXABAN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.79||||25.79||17.8|7.65
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|281.48||||281.48|126.67|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|281.48||||281.48|0|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|281.48||||281.48|83.46|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|281.48||||281.48|132.3|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|281.48||||281.48|0|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|281.48||||281.48|140.74|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|281.48||||281.48|177.33|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|281.48||||281.48|83.46|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|281.48||||281.48|154.81|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|281.48||||281.48|194.22|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|281.48||||281.48|0.14|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|281.48||||281.48|0|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|281.48||||281.48|83.46|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|281.48||||281.48|0|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|281.48||||281.48|83.46|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|281.48||||281.48|83.46|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|281.48||||281.48|194.22|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|281.48||||281.48|83.46|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|281.48||||281.48|98.52|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|281.48||||281.48|83.46|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|281.48||||281.48|83.46|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|281.48||||281.48|126.67|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|281.48||||281.48|126.67|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|281.48||||281.48||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AARP [1000]|AARP [100000]|258.17||||258.17|116.18|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258.17||||258.17||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AETNA [1015]|AETNA [101529]|258.17||||258.17|0|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258.17||||258.17|76.55|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258.17||||258.17||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258.17||||258.17||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BCBS UTHCT [115568]|258.17||||258.17|121.34|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258.17||||258.17|0|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258.17||||258.17|129.09|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258.17||||258.17|162.65|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258.17||||258.17|76.55|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258.17||||258.17||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|CIGNA [1260]|CIGNA GWH [126023]|258.17||||258.17|141.99|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|258.17||||258.17|178.14|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258.17||||258.17|0.14|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258.17||||258.17||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258.17||||258.17|0|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258.17||||258.17|76.55|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258.17||||258.17||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258.17||||258.17|0|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258.17||||258.17|76.55|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|258.17||||258.17|76.55|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|258.17||||258.17|178.14|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258.17||||258.17|76.55|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|Self-pay|Self-pay|258.17||||258.17|90.36|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258.17||||258.17|76.55|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258.17||||258.17|76.55|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258.17||||258.17|116.18|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258.17||||258.17||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258.17||||258.17||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258.17||||258.17|116.18|194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258.17||||258.17||194.22|0.14
119842|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|IOHEXOL 300 MG IODINE/ML INTRAVENOUS SOLUTION|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258.17||||258.17||194.22|0.14
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AARP [1000]|AARP [100000]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AETNA [1015]|AETNA [101529]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS [1155]|BCBS UTHCT [115568]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|CIGNA [1260]|CIGNA GWH [126023]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|Self-pay|Self-pay|604||||604|211.4|211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|604||||604||211.4|211.4
12000000|EAP|0120 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-GENERAL|HC SEMI-PRIVATE ROOM GENERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|604||||604||211.4|211.4
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|10218.97||||10218.97|5109.49|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10218.97||||10218.97|3452.58|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|10218.97||||10218.97|7876.8|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10218.97||||10218.97|3029.92|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10218.97||||10218.97|3418.4|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10218.97||||10218.97|3418.4|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|10218.97||||10218.97|4802.92|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10218.97||||10218.97|0|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10218.97||||10218.97|5109.49|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10218.97||||10218.97|6437.95|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10218.97||||10218.97|3029.92|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10218.97||||10218.97|3418.4|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|10218.97||||10218.97|5109.49|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10218.97||||10218.97|7051.09|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10218.97||||10218.97|41.06|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10218.97||||10218.97|3418.4|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10218.97||||10218.97|7876.8|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10218.97||||10218.97|3029.92|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10218.97||||10218.97|3418.4|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10218.97||||10218.97|7876.8|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10218.97||||10218.97|3029.92|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10218.97||||10218.97|3029.92|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10218.97||||10218.97|7051.09|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10218.97||||10218.97|3029.92|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|10218.97||||10218.97|3576.64|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10218.97||||10218.97|3029.92|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10218.97||||10218.97|3029.92|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10218.97||||10218.97|5109.49|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10218.97||||10218.97|3418.4|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10218.97||||10218.97|3418.4|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10218.97||||10218.97|5109.49|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10218.97||||10218.97|3418.4|7876.8|41.06
120086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 100 MG INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10218.97||||10218.97|6836.8|7876.8|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|AARP [1000]|AARP [100000]|16350.33||||16350.33|8175.17|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16350.33||||16350.33|5524.13|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|AETNA [1015]|AETNA [101529]|16350.33||||16350.33|12602.88|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16350.33||||16350.33|4847.87|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16350.33||||16350.33|5469.44|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16350.33||||16350.33|5469.44|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|BCBS [1155]|BCBS UTHCT [115568]|16350.33||||16350.33|7684.66|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16350.33||||16350.33|0|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16350.33||||16350.33|8175.17|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16350.33||||16350.33|10300.71|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16350.33||||16350.33|4847.87|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16350.33||||16350.33|5469.44|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|CIGNA [1260]|CIGNA GWH [126023]|16350.33||||16350.33|8175.17|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|16350.33||||16350.33|11281.73|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16350.33||||16350.33|41.06|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16350.33||||16350.33|5469.44|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16350.33||||16350.33|12602.88|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16350.33||||16350.33|4847.87|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16350.33||||16350.33|5469.44|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16350.33||||16350.33|12602.88|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16350.33||||16350.33|4847.87|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|16350.33||||16350.33|4847.87|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|16350.33||||16350.33|11281.73|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16350.33||||16350.33|4847.87|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|Self-pay|Self-pay|16350.33||||16350.33|5722.62|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16350.33||||16350.33|4847.87|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16350.33||||16350.33|4847.87|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16350.33||||16350.33|8175.17|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16350.33||||16350.33|5469.44|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16350.33||||16350.33|5469.44|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16350.33||||16350.33|8175.17|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16350.33||||16350.33|5469.44|12602.88|41.06
120087|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADO-TRASTUZUMAB EMTANSINE 160 MG INTRAVENOUS SOLUTION|160 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16350.33||||16350.33|10938.88|12602.88|41.06
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|AARP [1000]|AARP [100000]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|AETNA [1015]|AETNA [101529]|7404.26||||7404.26|5472|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7404.26||||7404.26|2195.36|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|BCBS [1155]|BCBS UTHCT [115568]|7404.26||||7404.26|3480|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7404.26||||7404.26|0|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7404.26||||7404.26|3702.13|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7404.26||||7404.26|4664.68|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7404.26||||7404.26|2195.36|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|CIGNA [1260]|CIGNA GWH [126023]|7404.26||||7404.26|3702.13|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|7404.26||||7404.26|5108.94|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7404.26||||7404.26|7.13|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7404.26||||7404.26|5472|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7404.26||||7404.26|2195.36|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7404.26||||7404.26|5472|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7404.26||||7404.26|2195.36|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|7404.26||||7404.26|2195.36|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|7404.26||||7404.26|5108.94|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7404.26||||7404.26|2195.36|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|Self-pay|Self-pay|7404.26||||7404.26|2591.49|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7404.26||||7404.26|2195.36|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7404.26||||7404.26|2195.36|5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7404.26||||7404.26||5472|7.13
120173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE ER 400 MG INTRAMUSCULAR SUSPENSION,EXTENDED RELEASE|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7404.26||||7404.26||5472|7.13
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.54||||1.54|0.68|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.54||||1.54|0.46|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.54||||1.54|0.72|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.54||||1.54|0.77|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.54||||1.54|0.77|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.54||||1.54|0.97|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.54||||1.54|0.46|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.54||||1.54|0.85|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.54||||1.54|1.06|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.54||||1.54|0.77|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.54||||1.54|0.68|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.54||||1.54|0.46|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.54||||1.54|0.68|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.54||||1.54|0.46|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.54||||1.54|0.46|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.54||||1.54|1.06|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.54||||1.54|0.46|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.54||||1.54|0.54|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.54||||1.54|0.46|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.54||||1.54|0.46|1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.54||||1.54||1.06|0.46
12024|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MECLIZINE 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.54||||1.54||1.06|0.46
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AARP [1000]|AARP [100000]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AETNA [1015]|AETNA [101529]|5.33||||5.33|2.35|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.33||||5.33|1.58|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.33||||5.33|2.51|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.33||||5.33|2.67|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.33||||5.33|2.67|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.33||||5.33|3.36|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.33||||5.33|1.58|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.33||||5.33|2.93|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.33||||5.33|3.68|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.33||||5.33|2.67|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.33||||5.33|2.35|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.33||||5.33|1.58|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.33||||5.33|2.35|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.33||||5.33|1.58|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.33||||5.33|1.58|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.33||||5.33|3.68|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.33||||5.33|1.58|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|Self-pay|Self-pay|5.33||||5.33|1.87|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.33||||5.33|1.58|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.33||||5.33|1.58|3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.33||||5.33||3.68|1.58
12098|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE ER 300 MG TABLET,EXTENDED RELEASE,12 HR|0.5 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.33||||5.33||3.68|1.58
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|AARP [1000]|AARP [100000]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|AETNA [1015]|AETNA [101529]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|BCBS [1155]|BCBS UTHCT [115568]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|CIGNA [1260]|CIGNA GWH [126023]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|Self-pay|Self-pay|604||||604|211.4|211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|604||||604||211.4|211.4
12100000|EAP|0121 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-MEDICAL|HC SEMI-PRIVATE ROOM MED/SURG/GYN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|604||||604||211.4|211.4
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|AARP [1000]|AARP [100000]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|AETNA [1015]|AETNA [101529]|33.1||||33.1|14.6|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.1||||33.1|9.81|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|33.1||||33.1|15.56|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.1||||33.1|16.55|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.1||||33.1|16.55|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.1||||33.1|20.85|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.1||||33.1|9.81|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|33.1||||33.1|18.21|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|33.1||||33.1|22.84|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.1||||33.1|16.55|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.1||||33.1|14.6|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.1||||33.1|9.81|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.1||||33.1|14.6|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.1||||33.1|9.81|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.1||||33.1|9.81|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|33.1||||33.1|22.84|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.1||||33.1|9.81|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|Self-pay|Self-pay|33.1||||33.1|11.58|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.1||||33.1|9.81|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.1||||33.1|9.81|22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.1||||33.1||22.84|9.81
121529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 36,000-114,000-180,000 UNIT CAPSULE,DELAY REL|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.1||||33.1||22.84|9.81
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|AARP [1000]|AARP [100000]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|AETNA [1015]|AETNA [101529]|248||||248|109.37|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|248||||248|73.53|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|BCBS [1155]|BCBS UTHCT [115568]|248||||248|116.56|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|248||||248|124|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|248||||248|124|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|248||||248|156.24|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|248||||248|73.53|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|CIGNA [1260]|CIGNA GWH [126023]|248||||248|136.4|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|248||||248|171.12|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|248||||248|124|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|248||||248|109.37|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|248||||248|73.53|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|248||||248|109.37|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|248||||248|73.53|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|248||||248|73.53|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|248||||248|171.12|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|248||||248|73.53|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|Self-pay|Self-pay|248||||248|86.8|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|248||||248|73.53|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|248||||248|73.53|171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|248||||248||171.12|73.53
121732|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|248||||248||171.12|73.53
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AARP [1000]|AARP [100000]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AETNA [1015]|AETNA [101529]|0.66||||0.66|0.29|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.66||||0.66|0.2|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.66||||0.66|0.31|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.66||||0.66|0.33|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.66||||0.66|0.33|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.66||||0.66|0.42|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.66||||0.66|0.2|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.66||||0.66|0.36|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.66||||0.66|0.46|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.66||||0.66|0.33|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.66||||0.66|0.29|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.66||||0.66|0.2|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.66||||0.66|0.29|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.66||||0.66|0.2|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.66||||0.66|0.2|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.66||||0.66|0.46|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.66||||0.66|0.2|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|Self-pay|Self-pay|0.66||||0.66|0.23|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.66||||0.66|0.2|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.66||||0.66|0.2|0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.66||||0.66||0.46|0.2
121784|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SENNOSIDES 8.8 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.66||||0.66||0.46|0.2
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|17.05||||17.05|17.05|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.05||||17.05|5.06|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|17.05||||17.05|8.01|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.05||||17.05|0|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.05||||17.05|8.53|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.05||||17.05|10.74|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.05||||17.05|5.06|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|17.05||||17.05|9.38|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.05||||17.05|11.76|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.05||||17.05|6.18|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.05||||17.05|17.05|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.05||||17.05|5.06|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.05||||17.05|17.05|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.05||||17.05|5.06|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.05||||17.05|5.06|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.05||||17.05|11.76|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.05||||17.05|5.06|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|Self-pay|Self-pay|17.05||||17.05|5.97|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.05||||17.05|5.06|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.05||||17.05|5.06|17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.05||||17.05||17.05|5.06
121798|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIGOXIN 250 MCG/ML (0.25 MG/ML) INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.05||||17.05||17.05|5.06
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|58.44||||58.44|25.77|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58.44||||58.44|17.33|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|58.44||||58.44|27.47|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58.44||||58.44|29.22|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58.44||||58.44|29.22|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58.44||||58.44|36.82|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58.44||||58.44|17.33|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|58.44||||58.44|32.14|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|58.44||||58.44|40.32|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58.44||||58.44|29.22|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58.44||||58.44|25.77|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58.44||||58.44|17.33|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58.44||||58.44|25.77|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.44||||58.44|17.33|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|58.44||||58.44|17.33|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|58.44||||58.44|40.32|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58.44||||58.44|17.33|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|58.44||||58.44|20.45|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58.44||||58.44|17.33|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58.44||||58.44|17.33|40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58.44||||58.44||40.32|17.33
121872|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58.44||||58.44||40.32|17.33
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|31.35||||31.35|13.83|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.35||||31.35|9.3|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|31.35||||31.35|14.73|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.35||||31.35|15.68|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.35||||31.35|15.68|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.35||||31.35|19.75|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.35||||31.35|9.3|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|31.35||||31.35|17.24|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|31.35||||31.35|21.63|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.35||||31.35|15.68|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.35||||31.35|13.83|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.35||||31.35|9.3|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.35||||31.35|13.83|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.35||||31.35|9.3|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.35||||31.35|9.3|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|31.35||||31.35|21.63|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.35||||31.35|9.3|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|31.35||||31.35|10.97|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.35||||31.35|9.3|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.35||||31.35|9.3|21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.35||||31.35||21.63|9.3
121929|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.35||||31.35||21.63|9.3
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|AARP [1000]|AARP [100000]|35.38||||35.38|10.48|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.38||||35.38||33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|AETNA [1015]|AETNA [101529]|35.38||||35.38|33.94|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.38||||35.38|10.49|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.38||||35.38||33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.38||||35.38||33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|35.38||||35.38|16.63|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.38||||35.38|0|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.38||||35.38|17.69|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.38||||35.38|22.29|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.38||||35.38|10.49|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.38||||35.38||33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|35.38||||35.38|19.46|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|35.38||||35.38|24.41|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35.38||||35.38|17.69|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.38||||35.38||33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.38||||35.38|33.94|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.38||||35.38|10.49|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.38||||35.38||33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.38||||35.38|33.94|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.38||||35.38|10.49|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|35.38||||35.38|10.49|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|35.38||||35.38|24.41|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.38||||35.38|10.49|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|Self-pay|Self-pay|35.38||||35.38|12.38|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35.38||||35.38|10.49|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.38||||35.38|10.49|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.38||||35.38|10.48|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35.38||||35.38||33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35.38||||35.38||33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.38||||35.38|10.48|33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.38||||35.38||33.94|10.48
121934|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SODIUM SUCCINATE 100 MG SOLUTION FOR INJECTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.38||||35.38||33.94|10.48
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|1.01||||1.01|0.45|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.01||||1.01|0.3|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1.01||||1.01|0.47|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.01||||1.01|0.51|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.01||||1.01|0.51|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.01||||1.01|0.64|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.01||||1.01|0.3|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1.01||||1.01|0.56|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.01||||1.01|0.7|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.01||||1.01|0.51|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.01||||1.01|0.45|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.01||||1.01|0.3|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.01||||1.01|0.45|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.01||||1.01|0.3|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.01||||1.01|0.3|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.01||||1.01|0.7|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.01||||1.01|0.3|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|1.01||||1.01|0.35|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.01||||1.01|0.3|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.01||||1.01|0.3|0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.01||||1.01||0.7|0.3
121938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM HYDROXIDE 400 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.01||||1.01||0.7|0.3
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|AARP [1000]|AARP [100000]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|24.72||||24.72|10.9|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.72||||24.72|7.33|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|24.72||||24.72|11.62|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.72||||24.72|12.36|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.72||||24.72|12.36|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.72||||24.72|15.57|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.72||||24.72|7.33|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|24.72||||24.72|13.6|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.72||||24.72|17.06|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.72||||24.72|12.36|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.72||||24.72|10.9|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.72||||24.72|7.33|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.72||||24.72|10.9|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.72||||24.72|7.33|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.72||||24.72|7.33|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.72||||24.72|17.06|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.72||||24.72|7.33|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|Self-pay|Self-pay|24.72||||24.72|8.65|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.72||||24.72|7.33|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.72||||24.72|7.33|17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.72||||24.72||17.06|7.33
122|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.72||||24.72||17.06|7.33
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AARP [1000]|AARP [100000]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AETNA [1015]|AETNA [101529]|445.03||||445.03|196.26|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|445.03||||445.03|131.95|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS [1155]|BCBS UTHCT [115568]|445.03||||445.03|209.16|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|445.03||||445.03|222.52|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|445.03||||445.03|222.52|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|445.03||||445.03|280.37|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|445.03||||445.03|131.95|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|CIGNA [1260]|CIGNA GWH [126023]|445.03||||445.03|244.77|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|445.03||||445.03|307.07|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|445.03||||445.03|222.52|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|445.03||||445.03|196.26|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|445.03||||445.03|131.95|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|445.03||||445.03|196.26|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|445.03||||445.03|131.95|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|445.03||||445.03|131.95|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|445.03||||445.03|307.07|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|445.03||||445.03|131.95|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|Self-pay|Self-pay|445.03||||445.03|155.76|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|445.03||||445.03|131.95|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|445.03||||445.03|131.95|307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|445.03||||445.03||307.07|131.95
122009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|445.03||||445.03||307.07|131.95
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.12||||1.12|0.49|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.12||||1.12|0.33|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.12||||1.12|0.53|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.12||||1.12|0.56|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.12||||1.12|0.56|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.12||||1.12|0.71|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.12||||1.12|0.33|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.12||||1.12|0.62|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.12||||1.12|0.77|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.12||||1.12|0.56|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.12||||1.12|0.49|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.12||||1.12|0.33|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.12||||1.12|0.49|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.12||||1.12|0.33|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.12||||1.12|0.33|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.12||||1.12|0.77|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.12||||1.12|0.33|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|Self-pay|Self-pay|1.12||||1.12|0.39|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.12||||1.12|0.33|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.12||||1.12|0.33|0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.12||||1.12||0.77|0.33
12206|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.12||||1.12||0.77|0.33
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.1||||2.1|0.93|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.1||||2.1|0.62|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.1||||2.1|0.99|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.1||||2.1|1.05|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.1||||2.1|1.05|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.1||||2.1|1.32|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.1||||2.1|0.62|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.1||||2.1|1.16|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.1||||2.1|1.45|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.1||||2.1|1.05|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.1||||2.1|0.93|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.1||||2.1|0.62|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.1||||2.1|0.93|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.1||||2.1|0.62|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.1||||2.1|0.62|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.1||||2.1|1.45|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.1||||2.1|0.62|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|Self-pay|Self-pay|2.1||||2.1|0.73|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.1||||2.1|0.62|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.1||||2.1|0.62|1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.1||||2.1||1.45|0.62
12207|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE 37.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.1||||2.1||1.45|0.62
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AARP [1000]|AARP [100000]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AETNA [1015]|AETNA [101529]|356.26||||356.26|157.11|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|356.26||||356.26|105.63|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|356.26||||356.26|167.44|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|356.26||||356.26|178.13|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|356.26||||356.26|178.13|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|356.26||||356.26|224.44|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|356.26||||356.26|105.63|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|356.26||||356.26|195.94|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|356.26||||356.26|245.82|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|356.26||||356.26|178.13|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|356.26||||356.26|157.11|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|356.26||||356.26|105.63|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|356.26||||356.26|157.11|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|356.26||||356.26|105.63|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|356.26||||356.26|105.63|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|356.26||||356.26|245.82|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|356.26||||356.26|105.63|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|Self-pay|Self-pay|356.26||||356.26|124.69|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|356.26||||356.26|105.63|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|356.26||||356.26|105.63|245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|356.26||||356.26||245.82|105.63
12211|ERX|0250 - PHARMACY-GENERAL|DORNASE ALFA 1 MG/ML SOLUTION FOR INHALATION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|356.26||||356.26||245.82|105.63
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|4719.75||||4719.75|1533.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4719.75||||4719.75|898.5|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|4719.75||||4719.75|1981.44|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4719.75||||4719.75|1399.41|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4719.75||||4719.75|889.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4719.75||||4719.75|889.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|4719.75||||4719.75|2218.28|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4719.75||||4719.75|0|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4719.75||||4719.75|2359.88|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4719.75||||4719.75|2973.44|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4719.75||||4719.75|1399.41|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4719.75||||4719.75|889.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|4719.75||||4719.75|2359.88|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4719.75||||4719.75|3256.63|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4719.75||||4719.75|53.04|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4719.75||||4719.75|889.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4719.75||||4719.75|1981.44|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4719.75||||4719.75|1399.41|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4719.75||||4719.75|889.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4719.75||||4719.75|1981.44|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4719.75||||4719.75|1399.41|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4719.75||||4719.75|1399.41|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4719.75||||4719.75|3256.63|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4719.75||||4719.75|1399.41|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|4719.75||||4719.75|1651.91|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4719.75||||4719.75|1399.41|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4719.75||||4719.75|1399.41|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4719.75||||4719.75|1533.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4719.75||||4719.75|889.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4719.75||||4719.75|889.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4719.75||||4719.75|1533.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4719.75||||4719.75|889.6|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4719.75||||4719.75|1779.2|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AARP [1000]|AARP [100000]|9439.5||||9439.5|4719.75|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9439.5||||9439.5|1796.99|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AETNA [1015]|AETNA [101529]|9439.5||||9439.5|3962.88|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9439.5||||9439.5|2798.81|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9439.5||||9439.5|1779.2|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9439.5||||9439.5|1779.2|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BCBS UTHCT [115568]|9439.5||||9439.5|4436.57|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9439.5||||9439.5|0|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9439.5||||9439.5|4719.75|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9439.5||||9439.5|5946.89|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9439.5||||9439.5|2798.81|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9439.5||||9439.5|1779.2|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA GWH [126023]|9439.5||||9439.5|4719.75|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9439.5||||9439.5|6513.26|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9439.5||||9439.5|53.04|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9439.5||||9439.5|1779.2|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9439.5||||9439.5|3962.88|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9439.5||||9439.5|2798.81|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9439.5||||9439.5|1779.2|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9439.5||||9439.5|3962.88|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9439.5||||9439.5|2798.81|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9439.5||||9439.5|2798.81|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9439.5||||9439.5|6513.26|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9439.5||||9439.5|2798.81|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|Self-pay|Self-pay|9439.5||||9439.5|3303.82|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9439.5||||9439.5|2798.81|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9439.5||||9439.5|2798.81|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9439.5||||9439.5|4719.75|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9439.5||||9439.5|1779.2|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9439.5||||9439.5|1779.2|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9439.5||||9439.5|4719.75|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9439.5||||9439.5|1779.2|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9439.5||||9439.5|3558.4|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|AARP [1000]|AARP [100000]|18879||||18879|9439.5|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18879||||18879|3593.98|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|AETNA [1015]|AETNA [101529]|18879||||18879|7925.76|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18879||||18879|5597.62|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18879||||18879|3558.4|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18879||||18879|3558.4|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|BCBS [1155]|BCBS UTHCT [115568]|18879||||18879|8873.13|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18879||||18879|0|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18879||||18879|9439.5|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18879||||18879|11893.77|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18879||||18879|5597.62|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18879||||18879|3558.4|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|CIGNA [1260]|CIGNA GWH [126023]|18879||||18879|9439.5|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18879||||18879|13026.51|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18879||||18879|53.04|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18879||||18879|3558.4|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18879||||18879|7925.76|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18879||||18879|5597.62|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18879||||18879|3558.4|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18879||||18879|7925.76|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18879||||18879|5597.62|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18879||||18879|5597.62|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18879||||18879|13026.51|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18879||||18879|5597.62|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|Self-pay|Self-pay|18879||||18879|6607.65|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18879||||18879|5597.62|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18879||||18879|5597.62|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18879||||18879|9439.5|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18879||||18879|3558.4|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18879||||18879|3558.4|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18879||||18879|9439.5|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18879||||18879|3558.4|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|400 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18879||||18879|7116.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|2359.88||||2359.88|766.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2359.88||||2359.88|449.25|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|2359.88||||2359.88|990.72|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2359.88||||2359.88|699.7|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2359.88||||2359.88|444.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2359.88||||2359.88|444.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|2359.88||||2359.88|1109.14|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2359.88||||2359.88|0|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2359.88||||2359.88|1179.94|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2359.88||||2359.88|1486.72|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2359.88||||2359.88|699.7|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2359.88||||2359.88|444.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|2359.88||||2359.88|1179.94|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2359.88||||2359.88|1628.32|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2359.88||||2359.88|53.04|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2359.88||||2359.88|444.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2359.88||||2359.88|990.72|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2359.88||||2359.88|699.7|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2359.88||||2359.88|444.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2359.88||||2359.88|990.72|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2359.88||||2359.88|699.7|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2359.88||||2359.88|699.7|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2359.88||||2359.88|1628.32|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2359.88||||2359.88|699.7|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|2359.88||||2359.88|825.96|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2359.88||||2359.88|699.7|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2359.88||||2359.88|699.7|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2359.88||||2359.88|766.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2359.88||||2359.88|444.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2359.88||||2359.88|444.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2359.88||||2359.88|766.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2359.88||||2359.88|444.8|13026.51|53.04
122149|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IMMUNE GLOB,GAMM(IGG) 10 %-PRO-IGA 0 TO 50 MCG/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2359.88||||2359.88|889.6|13026.51|53.04
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AARP [1000]|AARP [100000]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|34.1||||34.1|15.04|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.1||||34.1|10.11|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|34.1||||34.1|16.03|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.1||||34.1|17.05|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.1||||34.1|17.05|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.1||||34.1|21.48|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.1||||34.1|10.11|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|34.1||||34.1|18.76|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|34.1||||34.1|23.53|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34.1||||34.1|17.05|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.1||||34.1|15.04|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.1||||34.1|10.11|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.1||||34.1|15.04|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.1||||34.1|10.11|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|34.1||||34.1|10.11|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|34.1||||34.1|23.53|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.1||||34.1|10.11|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|Self-pay|Self-pay|34.1||||34.1|11.93|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34.1||||34.1|10.11|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.1||||34.1|10.11|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.1||||34.1||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|2.79||||2.79|1.23|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.79||||2.79|0.83|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|2.79||||2.79|1.31|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.79||||2.79|1.4|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.79||||2.79|1.4|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.79||||2.79|1.76|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.79||||2.79|0.83|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|2.79||||2.79|1.53|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.79||||2.79|1.93|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.79||||2.79|1.4|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.79||||2.79|1.23|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.79||||2.79|0.83|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.79||||2.79|1.23|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.79||||2.79|0.83|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.79||||2.79|0.83|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.79||||2.79|1.93|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.79||||2.79|0.83|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|Self-pay|Self-pay|2.79||||2.79|0.98|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.79||||2.79|0.83|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.79||||2.79|0.83|23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.79||||2.79||23.53|0.83
122165|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % VISCOUS MUCOSAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.79||||2.79||23.53|0.83
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|AARP [1000]|AARP [100000]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|278.22||||278.22|122.7|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|278.22||||278.22|82.49|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|278.22||||278.22|130.76|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|278.22||||278.22|139.11|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|278.22||||278.22|139.11|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|278.22||||278.22|175.28|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|278.22||||278.22|82.49|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|278.22||||278.22|153.02|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|278.22||||278.22|191.97|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|278.22||||278.22|139.11|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|278.22||||278.22|122.7|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|278.22||||278.22|82.49|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|278.22||||278.22|122.7|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|278.22||||278.22|82.49|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|278.22||||278.22|82.49|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|278.22||||278.22|191.97|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|278.22||||278.22|82.49|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|Self-pay|Self-pay|278.22||||278.22|97.38|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|278.22||||278.22|82.49|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|278.22||||278.22|82.49|191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|278.22||||278.22||191.97|82.49
122171|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|278.22||||278.22||191.97|82.49
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AARP [1000]|AARP [100000]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AETNA [1015]|AETNA [101529]|47.12||||47.12|13.73|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|47.12||||47.12|13.97|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS [1155]|BCBS UTHCT [115568]|47.12||||47.12|22.15|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|47.12||||47.12|0|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|47.12||||47.12|23.56|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|47.12||||47.12|29.69|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|47.12||||47.12|13.97|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|CIGNA [1260]|CIGNA GWH [126023]|47.12||||47.12|25.92|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|47.12||||47.12|32.51|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|47.12||||47.12|2.19|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|47.12||||47.12|13.73|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|47.12||||47.12|13.97|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|47.12||||47.12|13.73|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|47.12||||47.12|13.97|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|47.12||||47.12|13.97|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|47.12||||47.12|32.51|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|47.12||||47.12|13.97|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|Self-pay|Self-pay|47.12||||47.12|16.49|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|47.12||||47.12|13.97|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|47.12||||47.12|13.97|32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|47.12||||47.12||32.51|2.19
122186|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 20 MG/100 ML(200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS PIGGYBK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|47.12||||47.12||32.51|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|19.38||||19.38|6.86|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.38||||19.38|5.75|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|19.38||||19.38|9.11|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.38||||19.38|0|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.38||||19.38|9.69|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.38||||19.38|12.21|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.38||||19.38|5.75|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|19.38||||19.38|10.66|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.38||||19.38|13.37|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.38||||19.38|2.19|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.38||||19.38|6.86|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.38||||19.38|5.75|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.38||||19.38|6.86|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.38||||19.38|5.75|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.38||||19.38|5.75|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.38||||19.38|13.37|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.38||||19.38|5.75|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|19.38||||19.38|6.78|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.38||||19.38|5.75|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.38||||19.38|5.75|13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.38||||19.38||13.37|2.19
122190|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MILRINONE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.38||||19.38||13.37|2.19
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|17.67||||17.67|7.79|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.67||||17.67|5.24|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|17.67||||17.67|8.3|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.67||||17.67|8.84|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.67||||17.67|8.84|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.67||||17.67|11.13|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.67||||17.67|5.24|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|17.67||||17.67|9.72|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.67||||17.67|12.19|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.67||||17.67|8.84|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.67||||17.67|7.79|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.67||||17.67|5.24|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.67||||17.67|7.79|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.67||||17.67|5.24|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.67||||17.67|5.24|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.67||||17.67|12.19|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.67||||17.67|5.24|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|Self-pay|Self-pay|17.67||||17.67|6.18|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.67||||17.67|5.24|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.67||||17.67|5.24|12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.67||||17.67||12.19|5.24
1222|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.67||||17.67||12.19|5.24
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|56.92||||56.92|25.1|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56.92||||56.92|16.88|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|56.92||||56.92|26.75|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56.92||||56.92|28.46|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56.92||||56.92|28.46|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56.92||||56.92|35.86|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56.92||||56.92|16.88|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|56.92||||56.92|31.31|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|56.92||||56.92|39.27|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|56.92||||56.92|28.46|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56.92||||56.92|25.1|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56.92||||56.92|16.88|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56.92||||56.92|25.1|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|56.92||||56.92|16.88|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|56.92||||56.92|16.88|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|56.92||||56.92|39.27|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56.92||||56.92|16.88|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|56.92||||56.92|19.92|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|56.92||||56.92|16.88|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56.92||||56.92|16.88|39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56.92||||56.92||39.27|16.88
122267|ERX|0250 - PHARMACY-GENERAL|NEOSTIGMINE METHYLSULFATE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|56.92||||56.92||39.27|16.88
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AARP [1000]|AARP [100000]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AETNA [1015]|AETNA [101529]|18.13||||18.13|10.22|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.13||||18.13|5.38|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BCBS UTHCT [115568]|18.13||||18.13|8.52|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.13||||18.13|0|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.13||||18.13|9.07|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.13||||18.13|11.42|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.13||||18.13|5.38|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|CIGNA [1260]|CIGNA GWH [126023]|18.13||||18.13|9.97|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|18.13||||18.13|12.51|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.13||||18.13|2.38|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.13||||18.13|10.22|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.13||||18.13|5.38|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.13||||18.13|10.22|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.13||||18.13|5.38|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.13||||18.13|5.38|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|18.13||||18.13|12.51|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.13||||18.13|5.38|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|Self-pay|Self-pay|18.13||||18.13|6.35|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.13||||18.13|5.38|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.13||||18.13|5.38|12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.13||||18.13||12.51|2.38
122284|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFUROXIME SODIUM 1.5 GRAM INTRAVENOUS SOLUTION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.13||||18.13||12.51|2.38
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|AARP [1000]|AARP [100000]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|AETNA [1015]|AETNA [101529]|185.54||||185.54|81.82|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|185.54||||185.54|55.01|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|BCBS [1155]|BCBS UTHCT [115568]|185.54||||185.54|87.2|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|185.54||||185.54|92.77|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|185.54||||185.54|92.77|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|185.54||||185.54|116.89|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|185.54||||185.54|55.01|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|CIGNA [1260]|CIGNA GWH [126023]|185.54||||185.54|102.05|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|185.54||||185.54|128.02|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|185.54||||185.54|92.77|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|185.54||||185.54|81.82|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|185.54||||185.54|55.01|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|185.54||||185.54|81.82|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|185.54||||185.54|55.01|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|185.54||||185.54|55.01|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|185.54||||185.54|128.02|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|185.54||||185.54|55.01|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|Self-pay|Self-pay|185.54||||185.54|64.94|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|185.54||||185.54|55.01|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|185.54||||185.54|55.01|128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|185.54||||185.54||128.02|55.01
122301|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG/5 ML ORAL SUSPENSION|450 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|185.54||||185.54||128.02|55.01
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AARP [1000]|AARP [100000]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA [1015]|AETNA [101529]|14.13||||14.13|6.23|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.13||||14.13|4.19|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|14.13||||14.13|6.64|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.13||||14.13|7.07|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.13||||14.13|7.07|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.13||||14.13|8.9|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.13||||14.13|4.19|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|14.13||||14.13|7.77|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|14.13||||14.13|9.75|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.13||||14.13|7.07|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.13||||14.13|6.23|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.13||||14.13|4.19|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.13||||14.13|6.23|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.13||||14.13|4.19|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.13||||14.13|4.19|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|14.13||||14.13|9.75|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.13||||14.13|4.19|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|Self-pay|Self-pay|14.13||||14.13|4.95|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.13||||14.13|4.19|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.13||||14.13|4.19|9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.13||||14.13||9.75|4.19
122363|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.13||||14.13||9.75|4.19
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AARP [1000]|AARP [100000]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA [1015]|AETNA [101529]|19.53||||19.53|8.61|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.53||||19.53|5.79|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|19.53||||19.53|9.18|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.53||||19.53|9.77|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.53||||19.53|9.77|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.53||||19.53|12.3|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.53||||19.53|5.79|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|19.53||||19.53|10.74|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.53||||19.53|13.48|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.53||||19.53|9.77|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.53||||19.53|8.61|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.53||||19.53|5.79|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.53||||19.53|8.61|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.53||||19.53|5.79|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.53||||19.53|5.79|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.53||||19.53|13.48|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.53||||19.53|5.79|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|Self-pay|Self-pay|19.53||||19.53|6.84|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.53||||19.53|5.79|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.53||||19.53|5.79|13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.53||||19.53||13.48|5.79
122366|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.53||||19.53||13.48|5.79
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AARP [1000]|AARP [100000]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AETNA [1015]|AETNA [101529]|45.05||||45.05|19.87|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45.05||||45.05|13.36|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|45.05||||45.05|21.17|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45.05||||45.05|22.53|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45.05||||45.05|22.53|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45.05||||45.05|28.38|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45.05||||45.05|13.36|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|45.05||||45.05|24.78|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|45.05||||45.05|31.08|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|45.05||||45.05|22.53|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45.05||||45.05|19.87|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45.05||||45.05|13.36|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45.05||||45.05|19.87|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45.05||||45.05|13.36|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|45.05||||45.05|13.36|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|45.05||||45.05|31.08|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45.05||||45.05|13.36|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|Self-pay|Self-pay|45.05||||45.05|15.77|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|45.05||||45.05|13.36|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45.05||||45.05|13.36|31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45.05||||45.05||31.08|13.36
122368|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45.05||||45.05||31.08|13.36
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|AARP [1000]|AARP [100000]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|AETNA [1015]|AETNA [101529]|35.64||||35.64|15.72|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.64||||35.64|10.57|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|BCBS [1155]|BCBS UTHCT [115568]|35.64||||35.64|16.75|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.64||||35.64|17.82|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.64||||35.64|17.82|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.64||||35.64|22.45|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.64||||35.64|10.57|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|CIGNA [1260]|CIGNA GWH [126023]|35.64||||35.64|19.6|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|GROUP PENSION ADMIN [1450]|GPA [145000]|35.64||||35.64|24.59|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35.64||||35.64|17.82|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.64||||35.64|15.72|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.64||||35.64|10.57|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.64||||35.64|15.72|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.64||||35.64|10.57|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|35.64||||35.64|10.57|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|PHCS [1780]|PHCS MULTIPLAN [178000]|35.64||||35.64|24.59|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.64||||35.64|10.57|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|Self-pay|Self-pay|35.64||||35.64|12.47|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35.64||||35.64|10.57|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.64||||35.64|10.57|24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.64||||35.64||24.59|10.57
122480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLCELLULOSE (LAXATIVE) ORAL POWDER|479 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.64||||35.64||24.59|10.57
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|3748.14||||3748.14|1185|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3748.14||||3748.14|848.4|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|3748.14||||3748.14|2016|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3748.14||||3748.14|1111.32|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3748.14||||3748.14|840|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3748.14||||3748.14|840|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|3748.14||||3748.14|1761.63|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3748.14||||3748.14|0|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3748.14||||3748.14|1874.07|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3748.14||||3748.14|2361.33|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3748.14||||3748.14|1111.32|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3748.14||||3748.14|840|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|3748.14||||3748.14|1874.07|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3748.14||||3748.14|2586.22|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3748.14||||3748.14|1.41|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3748.14||||3748.14|840|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3748.14||||3748.14|2016|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3748.14||||3748.14|1111.32|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3748.14||||3748.14|840|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3748.14||||3748.14|2016|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3748.14||||3748.14|1111.32|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3748.14||||3748.14|1111.32|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3748.14||||3748.14|2586.22|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3748.14||||3748.14|1111.32|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|3748.14||||3748.14|1311.85|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3748.14||||3748.14|1111.32|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3748.14||||3748.14|1111.32|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3748.14||||3748.14|1185|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3748.14||||3748.14|840|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3748.14||||3748.14|840|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3748.14||||3748.14|1185|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3748.14||||3748.14|840|2586.22|1.41
122648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERRIC CARBOXYMALTOSE 50 MG IRON/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3748.14||||3748.14|1680|2586.22|1.41
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|1384.95||||1384.95|610.76|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1384.95||||1384.95|410.64|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1384.95||||1384.95|650.93|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1384.95||||1384.95|692.48|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1384.95||||1384.95|692.48|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1384.95||||1384.95|872.52|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1384.95||||1384.95|410.64|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1384.95||||1384.95|761.72|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1384.95||||1384.95|955.62|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1384.95||||1384.95|692.48|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1384.95||||1384.95|610.76|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1384.95||||1384.95|410.64|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1384.95||||1384.95|610.76|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1384.95||||1384.95|410.64|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1384.95||||1384.95|410.64|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1384.95||||1384.95|955.62|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1384.95||||1384.95|410.64|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|Self-pay|Self-pay|1384.95||||1384.95|484.73|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1384.95||||1384.95|410.64|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1384.95||||1384.95|410.64|955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1384.95||||1384.95||955.62|410.64
122718|ERX|0250 - PHARMACY-GENERAL|ETHANOL (ETHYL ALCOHOL) 98 % INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1384.95||||1384.95||955.62|410.64
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|139.13||||139.13|61.36|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139.13||||139.13|41.25|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|139.13||||139.13|65.39|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139.13||||139.13|69.57|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139.13||||139.13|69.57|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139.13||||139.13|87.65|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139.13||||139.13|41.25|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|139.13||||139.13|76.52|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|139.13||||139.13|96|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|139.13||||139.13|69.57|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139.13||||139.13|61.36|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139.13||||139.13|41.25|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139.13||||139.13|61.36|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139.13||||139.13|41.25|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|139.13||||139.13|41.25|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|139.13||||139.13|96|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139.13||||139.13|41.25|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|Self-pay|Self-pay|139.13||||139.13|48.7|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|139.13||||139.13|41.25|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139.13||||139.13|41.25|96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139.13||||139.13||96|41.25
122968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LURASIDONE 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139.13||||139.13||96|41.25
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|AARP [1000]|AARP [100000]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|64.64||||64.64|28.51|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64.64||||64.64|19.17|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|64.64||||64.64|30.38|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64.64||||64.64|32.32|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64.64||||64.64|32.32|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64.64||||64.64|40.72|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64.64||||64.64|19.17|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|64.64||||64.64|35.55|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|64.64||||64.64|44.6|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|64.64||||64.64|32.32|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64.64||||64.64|28.51|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64.64||||64.64|19.17|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64.64||||64.64|28.51|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64.64||||64.64|19.17|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|64.64||||64.64|19.17|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|64.64||||64.64|44.6|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64.64||||64.64|19.17|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|Self-pay|Self-pay|64.64||||64.64|22.62|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|64.64||||64.64|19.17|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64.64||||64.64|19.17|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64.64||||64.64||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AARP [1000]|AARP [100000]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|37.2||||37.2|16.41|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.2||||37.2|11.03|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|37.2||||37.2|17.48|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.2||||37.2|18.6|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.2||||37.2|18.6|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.2||||37.2|23.44|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.2||||37.2|11.03|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|37.2||||37.2|20.46|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|37.2||||37.2|25.67|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|37.2||||37.2|18.6|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.2||||37.2|16.41|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.2||||37.2|11.03|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.2||||37.2|16.41|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.2||||37.2|11.03|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|37.2||||37.2|11.03|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|37.2||||37.2|25.67|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.2||||37.2|11.03|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|Self-pay|Self-pay|37.2||||37.2|13.02|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|37.2||||37.2|11.03|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.2||||37.2|11.03|44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.2||||37.2||44.6|11.03
123|ERX|0250 - PHARMACY-GENERAL|ACETYLCYSTEINE 200 MG/ML (20 %) PO/NEB SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.2||||37.2||44.6|11.03
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|16.81||||16.81|7.41|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.81||||16.81|4.98|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|16.81||||16.81|7.9|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.81||||16.81|8.41|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.81||||16.81|8.41|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.81||||16.81|10.59|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.81||||16.81|4.98|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|16.81||||16.81|9.25|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.81||||16.81|11.6|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.81||||16.81|8.41|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.81||||16.81|7.41|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.81||||16.81|4.98|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.81||||16.81|7.41|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.81||||16.81|4.98|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.81||||16.81|4.98|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.81||||16.81|11.6|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.81||||16.81|4.98|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|16.81||||16.81|5.88|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.81||||16.81|4.98|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.81||||16.81|4.98|11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.81||||16.81||11.6|4.98
123049|ERX|0250 - PHARMACY-GENERAL|DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.81||||16.81||11.6|4.98
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|AARP [1000]|AARP [100000]|4969.3||||4969.3|1732.85|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4969.3||||4969.3|1596.55|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|AETNA [1015]|AETNA [101529]|4969.3||||4969.3|3779.16|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4969.3||||4969.3|1473.4|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4969.3||||4969.3|1580.74|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4969.3||||4969.3|1580.74|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|BCBS [1155]|BCBS UTHCT [115568]|4969.3||||4969.3|2335.57|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4969.3||||4969.3|0|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4969.3||||4969.3|2484.65|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4969.3||||4969.3|3130.66|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4969.3||||4969.3|1473.4|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4969.3||||4969.3|1580.74|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|CIGNA [1260]|CIGNA GWH [126023]|4969.3||||4969.3|2484.65|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|4969.3||||4969.3|3428.82|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4969.3||||4969.3|55.84|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4969.3||||4969.3|1580.74|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4969.3||||4969.3|3779.16|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4969.3||||4969.3|1473.4|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4969.3||||4969.3|1580.74|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4969.3||||4969.3|3779.16|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4969.3||||4969.3|1473.4|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|4969.3||||4969.3|1473.4|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|4969.3||||4969.3|3428.82|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4969.3||||4969.3|1473.4|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|Self-pay|Self-pay|4969.3||||4969.3|1739.25|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4969.3||||4969.3|1473.4|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4969.3||||4969.3|1473.4|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4969.3||||4969.3|1732.85|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4969.3||||4969.3|1580.74|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4969.3||||4969.3|1580.74|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4969.3||||4969.3|1732.85|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4969.3||||4969.3|1580.74|3779.16|55.84
123070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INJECTION POWDER FOR SOLUTION|3.5 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4969.3||||4969.3|3161.48|3779.16|55.84
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|AARP [1000]|AARP [100000]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|49.6||||49.6|8.93|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49.6||||49.6|14.71|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|49.6||||49.6|23.31|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49.6||||49.6|0|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49.6||||49.6|24.8|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49.6||||49.6|31.25|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49.6||||49.6|14.71|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|49.6||||49.6|27.28|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|49.6||||49.6|34.22|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|49.6||||49.6|0.69|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49.6||||49.6|8.93|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49.6||||49.6|14.71|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49.6||||49.6|8.93|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49.6||||49.6|14.71|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|49.6||||49.6|14.71|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|49.6||||49.6|34.22|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49.6||||49.6|14.71|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|Self-pay|Self-pay|49.6||||49.6|17.36|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|49.6||||49.6|14.71|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49.6||||49.6|14.71|34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49.6||||49.6||34.22|0.69
123122|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SYRINGE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49.6||||49.6||34.22|0.69
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AARP [1000]|AARP [100000]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|170.35||||170.35|75.12|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170.35||||170.35|50.51|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|170.35||||170.35|80.06|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170.35||||170.35|85.18|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170.35||||170.35|85.18|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170.35||||170.35|107.32|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170.35||||170.35|50.51|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|170.35||||170.35|93.69|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|170.35||||170.35|117.54|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|170.35||||170.35|85.18|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170.35||||170.35|75.12|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170.35||||170.35|50.51|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170.35||||170.35|75.12|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|170.35||||170.35|50.51|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|170.35||||170.35|50.51|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|170.35||||170.35|117.54|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170.35||||170.35|50.51|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|Self-pay|Self-pay|170.35||||170.35|59.62|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|170.35||||170.35|50.51|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170.35||||170.35|50.51|117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170.35||||170.35||117.54|50.51
123420|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|170.35||||170.35||117.54|50.51
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|AARP [1000]|AARP [100000]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|AETNA [1015]|AETNA [101529]|0.89||||0.89|0.39|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.89||||0.89|0.26|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|BCBS [1155]|BCBS UTHCT [115568]|0.89||||0.89|0.42|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.89||||0.89|0.45|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.89||||0.89|0.45|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.89||||0.89|0.56|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.89||||0.89|0.26|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|CIGNA [1260]|CIGNA GWH [126023]|0.89||||0.89|0.49|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|0.89||||0.89|0.61|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.89||||0.89|0.45|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.89||||0.89|0.39|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.89||||0.89|0.26|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.89||||0.89|0.39|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.89||||0.89|0.26|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.89||||0.89|0.26|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|0.89||||0.89|0.61|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.89||||0.89|0.26|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|Self-pay|Self-pay|0.89||||0.89|0.31|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.89||||0.89|0.26|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.89||||0.89|0.26|0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.89||||0.89||0.61|0.26
123500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE (PF) 1.4 %-0.6 % EYE DROPS IN A DROPPERETTE|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.89||||0.89||0.61|0.26
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|6.17||||6.17|6.17|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.17||||6.17||6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|6.17||||6.17|1.2|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.17||||6.17|1.83|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.17||||6.17||6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.17||||6.17||6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|6.17||||6.17|2.9|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.17||||6.17|0|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.17||||6.17|3.09|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.17||||6.17|3.89|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.17||||6.17|1.83|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.17||||6.17||6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|6.17||||6.17|3.39|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.17||||6.17|4.26|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.17||||6.17|0.03|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.17||||6.17||6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.17||||6.17|1.2|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.17||||6.17|1.83|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.17||||6.17||6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.17||||6.17|1.2|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.17||||6.17|1.83|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.17||||6.17|1.83|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.17||||6.17|4.26|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.17||||6.17|1.83|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|6.17||||6.17|2.16|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.17||||6.17|1.83|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.17||||6.17|1.83|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.17||||6.17|6.17|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.17||||6.17||6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.17||||6.17||6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.17||||6.17|6.17|6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.17||||6.17||6.17|0.03
123657|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN LOCK FLUSH (PORCINE) 100 UNIT/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.17||||6.17||6.17|0.03
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|79.12||||79.12|34.89|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79.12||||79.12|23.46|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|79.12||||79.12|37.19|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79.12||||79.12|39.56|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79.12||||79.12|39.56|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79.12||||79.12|49.85|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79.12||||79.12|23.46|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|79.12||||79.12|43.52|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|79.12||||79.12|54.59|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|79.12||||79.12|39.56|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79.12||||79.12|34.89|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79.12||||79.12|23.46|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79.12||||79.12|34.89|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79.12||||79.12|23.46|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|79.12||||79.12|23.46|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|79.12||||79.12|54.59|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79.12||||79.12|23.46|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|79.12||||79.12|27.69|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|79.12||||79.12|23.46|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79.12||||79.12|23.46|54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79.12||||79.12||54.59|23.46
12370|ERX|0250 - PHARMACY-GENERAL|NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79.12||||79.12||54.59|23.46
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|2.5||||2.5|2.5|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.5||||2.5|0.74|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|2.5||||2.5|1.18|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.5||||2.5|0|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.5||||2.5|1.25|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.5||||2.5|1.58|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.5||||2.5|0.74|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|2.5||||2.5|1.38|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.5||||2.5|1.73|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.5||||2.5|12.93|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.5||||2.5|2.5|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.5||||2.5|0.74|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.5||||2.5|2.5|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.5||||2.5|0.74|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.5||||2.5|0.74|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.5||||2.5|1.73|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.5||||2.5|0.74|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|2.5||||2.5|0.87|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.5||||2.5|0.74|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.5||||2.5|0.74|12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.5||||2.5||12.93|0.74
123762|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMINOPHYLLINE 500 MG/20 ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.5||||2.5||12.93|0.74
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|AARP [1000]|AARP [100000]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|AETNA [1015]|AETNA [101529]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|BCBS [1155]|BCBS UTHCT [115568]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|CIGNA [1260]|CIGNA GWH [126023]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|Self-pay|Self-pay|822||||822|287.7|287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|822||||822||287.7|287.7
12400000|EAP|0124 - ROOM & BOARD-SEMIPRIVATE (TWO-BEDS)-PSYCHIA|HC SEMI-PRIVATE ROOM PSYCH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|822||||822||287.7|287.7
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AARP [1000]|AARP [100000]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AETNA [1015]|AETNA [101529]|14.82||||14.82|6.54|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.82||||14.82|4.39|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS [1155]|BCBS UTHCT [115568]|14.82||||14.82|6.97|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.82||||14.82|7.41|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.82||||14.82|7.41|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.82||||14.82|9.34|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.82||||14.82|4.39|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|CIGNA [1260]|CIGNA GWH [126023]|14.82||||14.82|8.15|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.82||||14.82|10.23|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.82||||14.82|7.41|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.82||||14.82|6.54|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.82||||14.82|4.39|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.82||||14.82|6.54|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.82||||14.82|4.39|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.82||||14.82|4.39|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.82||||14.82|10.23|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.82||||14.82|4.39|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|Self-pay|Self-pay|14.82||||14.82|5.19|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.82||||14.82|4.39|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.82||||14.82|4.39|10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.82||||14.82||10.23|4.39
124070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARTIFICIAL SALIVA (YERBA SANTA AND LYTES) SPRAY|59 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.82||||14.82||10.23|4.39
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|48.05||||48.05|21.19|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48.05||||48.05|14.25|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|48.05||||48.05|22.58|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48.05||||48.05|24.03|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48.05||||48.05|24.03|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48.05||||48.05|30.27|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48.05||||48.05|14.25|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|48.05||||48.05|26.43|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|48.05||||48.05|33.15|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|48.05||||48.05|24.03|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48.05||||48.05|21.19|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48.05||||48.05|14.25|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48.05||||48.05|21.19|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48.05||||48.05|14.25|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|48.05||||48.05|14.25|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|48.05||||48.05|33.15|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48.05||||48.05|14.25|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|48.05||||48.05|16.82|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|48.05||||48.05|14.25|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48.05||||48.05|14.25|33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48.05||||48.05||33.15|14.25
124422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOBRAMYCIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48.05||||48.05||33.15|14.25
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|AARP [1000]|AARP [100000]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|AETNA [1015]|AETNA [101529]|295.86||||295.86|75.55|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|295.86||||295.86|87.72|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|295.86||||295.86|139.05|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|295.86||||295.86|0|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|295.86||||295.86|147.93|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|295.86||||295.86|186.39|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|295.86||||295.86|87.72|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|295.86||||295.86|162.72|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|295.86||||295.86|204.14|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|295.86||||295.86|53.34|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|295.86||||295.86|75.55|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|295.86||||295.86|87.72|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|295.86||||295.86|75.55|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|295.86||||295.86|87.72|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|295.86||||295.86|87.72|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|295.86||||295.86|204.14|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|295.86||||295.86|87.72|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|Self-pay|Self-pay|295.86||||295.86|103.55|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|295.86||||295.86|87.72|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|295.86||||295.86|87.72|204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|295.86||||295.86||204.14|53.34
124440|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 300 MG/4 ML SOLUTION FOR NEBULIZATION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|295.86||||295.86||204.14|53.34
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|43.71||||43.71|19.28|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|43.71||||43.71|12.96|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|43.71||||43.71|20.54|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|43.71||||43.71|21.86|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|43.71||||43.71|21.86|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|43.71||||43.71|27.54|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|43.71||||43.71|12.96|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|43.71||||43.71|24.04|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|43.71||||43.71|30.16|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|43.71||||43.71|21.86|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|43.71||||43.71|19.28|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|43.71||||43.71|12.96|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|43.71||||43.71|19.28|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|43.71||||43.71|12.96|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|43.71||||43.71|12.96|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|43.71||||43.71|30.16|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|43.71||||43.71|12.96|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|43.71||||43.71|15.3|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|43.71||||43.71|12.96|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|43.71||||43.71|12.96|30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|43.71||||43.71||30.16|12.96
124537|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORTIOXETINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|43.71||||43.71||30.16|12.96
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|AARP [1000]|AARP [100000]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|AETNA [1015]|AETNA [101529]|31.67||||31.67|13.97|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.67||||31.67|9.39|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|31.67||||31.67|14.88|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.67||||31.67|15.84|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.67||||31.67|15.84|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.67||||31.67|19.95|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.67||||31.67|9.39|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|31.67||||31.67|17.42|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|31.67||||31.67|21.85|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.67||||31.67|15.84|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.67||||31.67|13.97|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.67||||31.67|9.39|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.67||||31.67|13.97|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.67||||31.67|9.39|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.67||||31.67|9.39|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|31.67||||31.67|21.85|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.67||||31.67|9.39|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|Self-pay|Self-pay|31.67||||31.67|11.08|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.67||||31.67|9.39|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.67||||31.67|9.39|21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.67||||31.67||21.85|9.39
124576|ERX|0250 - PHARMACY-GENERAL|BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.67||||31.67||21.85|9.39
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AARP [1000]|AARP [100000]|192.82||||192.82|53.5|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA [1015]|AETNA [101529]|192.82||||192.82|72|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|192.82||||192.82|57.17|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BCBS UTHCT [115568]|192.82||||192.82|90.63|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|192.82||||192.82|0|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|192.82||||192.82|96.41|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|192.82||||192.82|121.48|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|192.82||||192.82|57.17|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA [1260]|CIGNA GWH [126023]|192.82||||192.82|106.05|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|192.82||||192.82|133.05|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|192.82||||192.82|0.93|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|192.82||||192.82|72|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|192.82||||192.82|57.17|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|192.82||||192.82|72|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|192.82||||192.82|57.17|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|192.82||||192.82|57.17|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|192.82||||192.82|133.05|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|192.82||||192.82|57.17|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|Self-pay|Self-pay|192.82||||192.82|67.49|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|192.82||||192.82|57.17|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|192.82||||192.82|57.17|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|192.82||||192.82|53.5|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|192.82||||192.82|53.5|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|192.82||||192.82||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|385.64||||385.64|107|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|385.64||||385.64||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|385.64||||385.64|144|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|385.64||||385.64|114.34|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|385.64||||385.64||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|385.64||||385.64||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|385.64||||385.64|181.25|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|385.64||||385.64|0|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|385.64||||385.64|192.82|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|385.64||||385.64|242.95|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|385.64||||385.64|114.34|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|385.64||||385.64||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|385.64||||385.64|212.1|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|385.64||||385.64|266.09|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|385.64||||385.64|0.93|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|385.64||||385.64||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|385.64||||385.64|144|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|385.64||||385.64|114.34|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|385.64||||385.64||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|385.64||||385.64|144|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|385.64||||385.64|114.34|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|385.64||||385.64|114.34|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|385.64||||385.64|266.09|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|385.64||||385.64|114.34|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|385.64||||385.64|134.97|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|385.64||||385.64|114.34|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|385.64||||385.64|114.34|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|385.64||||385.64|107|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|385.64||||385.64||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|385.64||||385.64||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|385.64||||385.64|107|266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|385.64||||385.64||266.09|0.93
124656|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|385.64||||385.64||266.09|0.93
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|AARP [1000]|AARP [100000]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|AETNA [1015]|AETNA [101529]|1415.28||||1415.28|429.7|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1415.28||||1415.28|419.63|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|1415.28||||1415.28|665.18|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1415.28||||1415.28|0|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1415.28||||1415.28|707.64|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1415.28||||1415.28|891.63|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1415.28||||1415.28|419.63|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|1415.28||||1415.28|707.64|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1415.28||||1415.28|976.54|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1415.28||||1415.28|13.34|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1415.28||||1415.28|429.7|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1415.28||||1415.28|419.63|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1415.28||||1415.28|429.7|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1415.28||||1415.28|419.63|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1415.28||||1415.28|419.63|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1415.28||||1415.28|976.54|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1415.28||||1415.28|419.63|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|Self-pay|Self-pay|1415.28||||1415.28|495.35|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1415.28||||1415.28|419.63|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1415.28||||1415.28|419.63|976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1415.28||||1415.28||976.54|13.34
124667|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1415.28||||1415.28||976.54|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|AARP [1000]|AARP [100000]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|AETNA [1015]|AETNA [101529]|4245.83||||4245.83|1289.09|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4245.83||||4245.83|1258.89|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|BCBS [1155]|BCBS UTHCT [115568]|4245.83||||4245.83|1995.54|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4245.83||||4245.83|0|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4245.83||||4245.83|2122.92|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4245.83||||4245.83|2674.87|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4245.83||||4245.83|1258.89|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|CIGNA [1260]|CIGNA GWH [126023]|4245.83||||4245.83|2122.92|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4245.83||||4245.83|2929.62|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4245.83||||4245.83|13.34|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4245.83||||4245.83|1289.09|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4245.83||||4245.83|1258.89|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4245.83||||4245.83|1289.09|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4245.83||||4245.83|1258.89|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4245.83||||4245.83|1258.89|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4245.83||||4245.83|2929.62|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4245.83||||4245.83|1258.89|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|Self-pay|Self-pay|4245.83||||4245.83|1486.04|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4245.83||||4245.83|1258.89|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4245.83||||4245.83|1258.89|2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4245.83||||4245.83||2929.62|13.34
124668|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYLAN G-F 20  48 MG/6 ML INTRA-ARTICULAR SYRINGE|6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4245.83||||4245.83||2929.62|13.34
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|AARP [1000]|AARP [100000]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|AETNA [1015]|AETNA [101529]|1.18||||1.18|0.52|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.18||||1.18|0.35|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|1.18||||1.18|0.55|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.18||||1.18|0.59|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.18||||1.18|0.59|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.18||||1.18|0.74|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.18||||1.18|0.35|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|1.18||||1.18|0.65|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.18||||1.18|0.81|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.18||||1.18|0.59|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.18||||1.18|0.52|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.18||||1.18|0.35|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.18||||1.18|0.52|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.18||||1.18|0.35|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.18||||1.18|0.35|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.18||||1.18|0.81|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.18||||1.18|0.35|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|Self-pay|Self-pay|1.18||||1.18|0.41|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.18||||1.18|0.35|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.18||||1.18|0.35|0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.18||||1.18||0.81|0.35
124729|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE CONCENTRATE 2.5 MG/0.5 ML SOLUTION FOR NEBULIZATION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.18||||1.18||0.81|0.35
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|AARP [1000]|AARP [100000]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|AETNA [1015]|AETNA [101529]|189.4||||189.4|83.53|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189.4||||189.4|56.16|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|BCBS [1155]|BCBS UTHCT [115568]|189.4||||189.4|89.02|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189.4||||189.4|94.7|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189.4||||189.4|94.7|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189.4||||189.4|119.32|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189.4||||189.4|56.16|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|CIGNA [1260]|CIGNA GWH [126023]|189.4||||189.4|104.17|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|189.4||||189.4|130.69|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189.4||||189.4|94.7|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189.4||||189.4|83.53|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189.4||||189.4|56.16|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189.4||||189.4|83.53|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189.4||||189.4|56.16|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|189.4||||189.4|56.16|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|189.4||||189.4|130.69|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189.4||||189.4|56.16|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|Self-pay|Self-pay|189.4||||189.4|66.29|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189.4||||189.4|56.16|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189.4||||189.4|56.16|130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189.4||||189.4||130.69|56.16
124737|ERX|0250 - PHARMACY-GENERAL|SILVER ER TOPICAL GEL,EXTENDED RELEASE|44.4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189.4||||189.4||130.69|56.16
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AARP [1000]|AARP [100000]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AETNA [1015]|AETNA [101529]|13.26||||13.26|5.85|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.26||||13.26|3.93|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS [1155]|BCBS UTHCT [115568]|13.26||||13.26|6.23|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.26||||13.26|6.63|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.26||||13.26|6.63|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.26||||13.26|8.35|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.26||||13.26|3.93|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|CIGNA [1260]|CIGNA GWH [126023]|13.26||||13.26|7.29|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|GROUP PENSION ADMIN [1450]|GPA [145000]|13.26||||13.26|9.15|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.26||||13.26|6.63|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.26||||13.26|5.85|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.26||||13.26|3.93|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.26||||13.26|5.85|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.26||||13.26|3.93|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.26||||13.26|3.93|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|PHCS [1780]|PHCS MULTIPLAN [178000]|13.26||||13.26|9.15|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.26||||13.26|3.93|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|Self-pay|Self-pay|13.26||||13.26|4.64|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.26||||13.26|3.93|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.26||||13.26|3.93|9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.26||||13.26||9.15|3.93
124764|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYLEPHRINE 0.25 %-MINERAL OIL 14 %-PETROLATM 74.9 % RECTAL OINTMENT|57 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.26||||13.26||9.15|3.93
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|2123.12||||2123.12|1540.56|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2123.12||||2123.12|629.51|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|2123.12||||2123.12|997.87|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2123.12||||2123.12|0|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2123.12||||2123.12|1061.56|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2123.12||||2123.12|1337.57|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2123.12||||2123.12|629.51|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|2123.12||||2123.12|1061.56|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2123.12||||2123.12|1464.95|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2123.12||||2123.12|79.43|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2123.12||||2123.12|1540.56|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2123.12||||2123.12|629.51|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2123.12||||2123.12|1540.56|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2123.12||||2123.12|629.51|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2123.12||||2123.12|629.51|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2123.12||||2123.12|1464.95|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2123.12||||2123.12|629.51|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|2123.12||||2123.12|743.09|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2123.12||||2123.12|629.51|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2123.12||||2123.12|629.51|1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2123.12||||2123.12||1540.56|79.43
124767|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OBINUTUZUMAB 1,000 MG/40 ML INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2123.12||||2123.12||1540.56|79.43
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|AARP [1000]|AARP [100000]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|AETNA [1015]|AETNA [101529]|41.3||||41.3|18.21|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.3||||41.3|12.25|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|BCBS [1155]|BCBS UTHCT [115568]|41.3||||41.3|19.41|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.3||||41.3|20.65|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.3||||41.3|20.65|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.3||||41.3|26.02|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.3||||41.3|12.25|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|CIGNA [1260]|CIGNA GWH [126023]|41.3||||41.3|22.72|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|41.3||||41.3|28.5|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.3||||41.3|20.65|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.3||||41.3|18.21|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.3||||41.3|12.25|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.3||||41.3|18.21|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.3||||41.3|12.25|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.3||||41.3|12.25|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|41.3||||41.3|28.5|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.3||||41.3|12.25|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|Self-pay|Self-pay|41.3||||41.3|14.45|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.3||||41.3|12.25|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.3||||41.3|12.25|28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.3||||41.3||28.5|12.25
124815|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACTIVATED CHARCOAL 25 GRAM/120 ML ORAL SUSPENSION|120 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.3||||41.3||28.5|12.25
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|AARP [1000]|AARP [100000]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|AETNA [1015]|AETNA [101529]|753.3||||753.3|332.21|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|753.3||||753.3|223.35|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|BCBS [1155]|BCBS UTHCT [115568]|753.3||||753.3|354.05|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|753.3||||753.3|376.65|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|753.3||||753.3|376.65|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|753.3||||753.3|474.58|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|753.3||||753.3|223.35|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|CIGNA [1260]|CIGNA GWH [126023]|753.3||||753.3|414.32|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|753.3||||753.3|519.78|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|753.3||||753.3|376.65|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|753.3||||753.3|332.21|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|753.3||||753.3|223.35|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|753.3||||753.3|332.21|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|753.3||||753.3|223.35|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|753.3||||753.3|223.35|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|753.3||||753.3|519.78|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|753.3||||753.3|223.35|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|Self-pay|Self-pay|753.3||||753.3|263.65|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|753.3||||753.3|223.35|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|753.3||||753.3|223.35|519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|753.3||||753.3||519.78|223.35
124870|ERX|0250 - PHARMACY-GENERAL|CANDIDA ALBICANS SKIN TEST FDA STANDARD INTRADERMAL|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|753.3||||753.3||519.78|223.35
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.84||||0.84|0.37|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.84||||0.84|0.25|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.84||||0.84|0.39|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.84||||0.84|0.42|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.84||||0.84|0.42|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.84||||0.84|0.53|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.84||||0.84|0.25|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.84||||0.84|0.46|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.84||||0.84|0.58|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.84||||0.84|0.42|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.84||||0.84|0.37|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.84||||0.84|0.25|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.84||||0.84|0.37|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.84||||0.84|0.25|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.84||||0.84|0.25|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.84||||0.84|0.58|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.84||||0.84|0.25|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.84||||0.84|0.29|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.84||||0.84|0.25|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.84||||0.84|0.25|0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.84||||0.84||0.58|0.25
12491|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.84||||0.84||0.58|0.25
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|2.96||||2.96|1.31|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.96||||2.96|0.88|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|2.96||||2.96|1.39|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.96||||2.96|1.48|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.96||||2.96|1.48|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.96||||2.96|1.86|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.96||||2.96|0.88|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|2.96||||2.96|1.63|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.96||||2.96|2.04|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.96||||2.96|1.48|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.96||||2.96|1.31|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.96||||2.96|0.88|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.96||||2.96|1.31|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.96||||2.96|0.88|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.96||||2.96|0.88|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.96||||2.96|2.04|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.96||||2.96|0.88|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|2.96||||2.96|1.04|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.96||||2.96|0.88|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.96||||2.96|0.88|2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.96||||2.96||2.04|0.88
124962|ERX|0250 - PHARMACY-GENERAL|FAMOTIDINE (PF) 20 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.96||||2.96||2.04|0.88
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|AARP [1000]|AARP [100000]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|AETNA [1015]|AETNA [101529]|943.35||||943.35|416.02|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|943.35||||943.35|279.7|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|BCBS [1155]|BCBS UTHCT [115568]|943.35||||943.35|443.37|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|943.35||||943.35|471.68|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|943.35||||943.35|471.68|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|943.35||||943.35|594.31|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|943.35||||943.35|279.7|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|CIGNA [1260]|CIGNA GWH [126023]|943.35||||943.35|518.84|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|943.35||||943.35|650.91|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|943.35||||943.35|471.68|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|943.35||||943.35|416.02|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|943.35||||943.35|279.7|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|943.35||||943.35|416.02|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|943.35||||943.35|279.7|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|943.35||||943.35|279.7|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|943.35||||943.35|650.91|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|943.35||||943.35|279.7|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|Self-pay|Self-pay|943.35||||943.35|330.17|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|943.35||||943.35|279.7|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|943.35||||943.35|279.7|650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|943.35||||943.35||650.91|279.7
124985|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE (JR) 0.15 MG/0.3 ML INJECTION,AUTO-INJECTOR|0.3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|943.35||||943.35||650.91|279.7
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|AARP [1000]|AARP [100000]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|AETNA [1015]|AETNA [101529]|465||||465|205.07|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|465||||465|137.87|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|BCBS [1155]|BCBS UTHCT [115568]|465||||465|218.55|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|465||||465|232.5|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|465||||465|232.5|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|465||||465|292.95|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|465||||465|137.87|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|CIGNA [1260]|CIGNA GWH [126023]|465||||465|255.75|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|465||||465|320.85|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|465||||465|232.5|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|465||||465|205.07|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|465||||465|137.87|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|465||||465|205.07|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|465||||465|137.87|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|465||||465|137.87|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|465||||465|320.85|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|465||||465|137.87|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|Self-pay|Self-pay|465||||465|162.75|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|465||||465|137.87|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|465||||465|137.87|320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|465||||465||320.85|137.87
124987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EPINEPHRINE 0.3 MG/0.3 ML INJECTION, AUTO-INJECTOR|0.3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|465||||465||320.85|137.87
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AARP [1000]|AARP [100000]|27.13||||27.13|27.13|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.13||||27.13||27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AETNA [1015]|AETNA [101529]|27.13||||27.13|21.84|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.13||||27.13|8.04|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.13||||27.13||27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.13||||27.13||27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BCBS UTHCT [115568]|27.13||||27.13|12.75|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.13||||27.13|0|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.13||||27.13|13.57|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.13||||27.13|17.09|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.13||||27.13|8.04|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.13||||27.13||27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA [1260]|CIGNA GWH [126023]|27.13||||27.13|14.92|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.13||||27.13|18.72|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.13||||27.13|1.06|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.13||||27.13||27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.13||||27.13|21.84|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.13||||27.13|8.04|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.13||||27.13||27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.13||||27.13|21.84|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.13||||27.13|8.04|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.13||||27.13|8.04|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.13||||27.13|18.72|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.13||||27.13|8.04|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|Self-pay|Self-pay|27.13||||27.13|9.5|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.13||||27.13|8.04|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.13||||27.13|8.04|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.13||||27.13|27.13|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.13||||27.13||27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.13||||27.13||27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.13||||27.13|27.13|27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.13||||27.13||27.13|1.06
125001|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.13||||27.13||27.13|1.06
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|AARP [1000]|AARP [100000]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|AETNA [1015]|AETNA [101529]|323.77||||323.77|142.78|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|323.77||||323.77|96|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|BCBS [1155]|BCBS UTHCT [115568]|323.77||||323.77|152.17|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|323.77||||323.77|161.89|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|323.77||||323.77|161.89|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|323.77||||323.77|203.98|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|323.77||||323.77|96|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|CIGNA [1260]|CIGNA GWH [126023]|323.77||||323.77|178.07|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|323.77||||323.77|223.4|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|323.77||||323.77|161.89|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|323.77||||323.77|142.78|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|323.77||||323.77|96|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|323.77||||323.77|142.78|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|323.77||||323.77|96|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|323.77||||323.77|96|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|323.77||||323.77|223.4|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|323.77||||323.77|96|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|Self-pay|Self-pay|323.77||||323.77|113.32|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|323.77||||323.77|96|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|323.77||||323.77|96|223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|323.77||||323.77||223.4|96
125036|ERX|0250 - PHARMACY-GENERAL|UMECLIDINIUM 62.5 MCG-VILANTEROL 25 MCG/ACTUATION POWDR FOR INHALATION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|323.77||||323.77||223.4|96
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|40.61||||40.61|7.39|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40.61||||40.61|12.04|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|40.61||||40.61|19.09|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40.61||||40.61|0|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40.61||||40.61|20.31|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40.61||||40.61|25.58|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40.61||||40.61|12.04|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|40.61||||40.61|22.34|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|40.61||||40.61|28.02|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|40.61||||40.61|1.03|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40.61||||40.61|7.39|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40.61||||40.61|12.04|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40.61||||40.61|7.39|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40.61||||40.61|12.04|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|40.61||||40.61|12.04|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|40.61||||40.61|28.02|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40.61||||40.61|12.04|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|40.61||||40.61|14.21|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|40.61||||40.61|12.04|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40.61||||40.61|12.04|28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40.61||||40.61||28.02|1.03
125145|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 2 GRAM/100 ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40.61||||40.61||28.02|1.03
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|AARP [1000]|AARP [100000]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|AETNA [1015]|AETNA [101529]|14.1||||14.1|6.22|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.1||||14.1|4.18|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|BCBS [1155]|BCBS UTHCT [115568]|14.1||||14.1|6.63|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.1||||14.1|7.05|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.1||||14.1|7.05|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.1||||14.1|8.88|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.1||||14.1|4.18|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|CIGNA [1260]|CIGNA GWH [126023]|14.1||||14.1|7.76|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|14.1||||14.1|9.73|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.1||||14.1|7.05|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.1||||14.1|6.22|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.1||||14.1|4.18|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.1||||14.1|6.22|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.1||||14.1|4.18|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.1||||14.1|4.18|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|14.1||||14.1|9.73|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.1||||14.1|4.18|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|Self-pay|Self-pay|14.1||||14.1|4.93|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.1||||14.1|4.18|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.1||||14.1|4.18|9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.1||||14.1||9.73|4.18
125379|ERX|0250 - PHARMACY-GENERAL|PHENOL 89 % TOPICAL SWAB|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.1||||14.1||9.73|4.18
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|AARP [1000]|AARP [100000]|823.46||||823.46|370.56|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|823.46||||823.46||568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|AETNA [1015]|AETNA [101529]|823.46||||823.46|231.41|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|823.46||||823.46|244.16|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|823.46||||823.46||568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|823.46||||823.46||568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|823.46||||823.46|387.03|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|823.46||||823.46|0|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|823.46||||823.46|411.73|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|823.46||||823.46|518.78|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|823.46||||823.46|244.16|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|823.46||||823.46||568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|823.46||||823.46|452.9|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|823.46||||823.46|568.19|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|823.46||||823.46|58.84|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|823.46||||823.46||568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|823.46||||823.46|231.41|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|823.46||||823.46|244.16|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|823.46||||823.46||568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|823.46||||823.46|231.41|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|823.46||||823.46|244.16|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|823.46||||823.46|244.16|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|823.46||||823.46|568.19|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|823.46||||823.46|244.16|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|Self-pay|Self-pay|823.46||||823.46|288.21|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|823.46||||823.46|244.16|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|823.46||||823.46|244.16|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|823.46||||823.46|370.56|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|823.46||||823.46||568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|823.46||||823.46||568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|823.46||||823.46|370.56|568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|823.46||||823.46||568.19|58.84
125504|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|PERFLUTREN LIPID MICROSPHERES 1.1 MG/ML INTRAVENOUS SUSPENSION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|823.46||||823.46||568.19|58.84
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|3894.47||||3894.47|1247.4|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3894.47||||3894.47|1266.34|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|3894.47||||3894.47|2930.88|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3894.47||||3894.47|1154.71|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3894.47||||3894.47|1253.8|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3894.47||||3894.47|1253.8|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|3894.47||||3894.47|1830.4|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3894.47||||3894.47|0|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3894.47||||3894.47|1947.24|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3894.47||||3894.47|2453.52|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3894.47||||3894.47|1154.71|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3894.47||||3894.47|1253.8|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|3894.47||||3894.47|1947.24|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3894.47||||3894.47|2687.18|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3894.47||||3894.47|77.08|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3894.47||||3894.47|1253.8|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3894.47||||3894.47|2930.88|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3894.47||||3894.47|1154.71|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3894.47||||3894.47|1253.8|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3894.47||||3894.47|2930.88|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3894.47||||3894.47|1154.71|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3894.47||||3894.47|1154.71|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3894.47||||3894.47|2687.18|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3894.47||||3894.47|1154.71|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|3894.47||||3894.47|1363.06|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3894.47||||3894.47|1154.71|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3894.47||||3894.47|1154.71|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3894.47||||3894.47|1247.4|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3894.47||||3894.47|1253.8|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3894.47||||3894.47|1253.8|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3894.47||||3894.47|1247.4|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3894.47||||3894.47|1253.8|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3894.47||||3894.47|2507.6|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|19472.34||||19472.34|9736.17|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19472.34||||19472.34|6331.69|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|19472.34||||19472.34|14654.4|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19472.34||||19472.34|5773.55|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19472.34||||19472.34|6269|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19472.34||||19472.34|6269|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|19472.34||||19472.34|9152|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19472.34||||19472.34|0|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19472.34||||19472.34|9736.17|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19472.34||||19472.34|12267.57|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19472.34||||19472.34|5773.55|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19472.34||||19472.34|6269|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|19472.34||||19472.34|9736.17|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19472.34||||19472.34|13435.91|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19472.34||||19472.34|77.08|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19472.34||||19472.34|6269|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19472.34||||19472.34|14654.4|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19472.34||||19472.34|5773.55|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19472.34||||19472.34|6269|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19472.34||||19472.34|14654.4|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19472.34||||19472.34|5773.55|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19472.34||||19472.34|5773.55|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19472.34||||19472.34|13435.91|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19472.34||||19472.34|5773.55|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|19472.34||||19472.34|6815.32|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19472.34||||19472.34|5773.55|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19472.34||||19472.34|5773.55|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19472.34||||19472.34|9736.17|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19472.34||||19472.34|6269|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19472.34||||19472.34|6269|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19472.34||||19472.34|9736.17|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19472.34||||19472.34|6269|14654.4|77.08
125686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RAMUCIRUMAB 10 MG/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19472.34||||19472.34|12538|14654.4|77.08
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AARP [1000]|AARP [100000]|16.43||||16.43|3.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AETNA [1015]|AETNA [101529]|16.43||||16.43|1.54|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BCBS UTHCT [115568]|16.43||||16.43|7.72|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.43||||16.43|0|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.43||||16.43|8.22|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.43||||16.43|10.35|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA [1260]|CIGNA GWH [126023]|16.43||||16.43|9.04|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.43||||16.43|11.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.43||||16.43|0.85|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.43||||16.43|1.54|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.43||||16.43|1.54|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.43||||16.43|11.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|Self-pay|Self-pay|16.43||||16.43|5.75|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.43||||16.43|3.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.43||||16.43|3.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AARP [1000]|AARP [100000]|16.43||||16.43|3.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AETNA [1015]|AETNA [101529]|16.43||||16.43|1.54|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS [1155]|BCBS UTHCT [115568]|16.43||||16.43|7.72|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.43||||16.43|0|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.43||||16.43|8.22|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.43||||16.43|10.35|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|CIGNA [1260]|CIGNA GWH [126023]|16.43||||16.43|9.04|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.43||||16.43|11.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.43||||16.43|0.85|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.43||||16.43|1.54|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.43||||16.43|1.54|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.43||||16.43|11.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|Self-pay|Self-pay|16.43||||16.43|5.75|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.43||||16.43|4.87|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.43||||16.43|3.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.43||||16.43|3.34|11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.43||||16.43||11.34|0.85
125739|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.43||||16.43||11.34|0.85
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AARP [1000]|AARP [100000]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AETNA [1015]|AETNA [101529]|16.43||||16.43|8.42|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BCBS UTHCT [115568]|16.43||||16.43|7.72|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.43||||16.43|0|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.43||||16.43|8.22|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.43||||16.43|10.35|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|CIGNA [1260]|CIGNA GWH [126023]|16.43||||16.43|9.04|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.43||||16.43|11.34|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.43||||16.43|4.91|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.43||||16.43|8.42|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.43||||16.43|8.42|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.43||||16.43|11.34|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|Self-pay|Self-pay|16.43||||16.43|5.75|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AARP [1000]|AARP [100000]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AETNA [1015]|AETNA [101529]|16.43||||16.43|8.42|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS [1155]|BCBS UTHCT [115568]|16.43||||16.43|7.72|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.43||||16.43|0|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.43||||16.43|8.22|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.43||||16.43|10.35|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|CIGNA [1260]|CIGNA GWH [126023]|16.43||||16.43|9.04|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.43||||16.43|11.34|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.43||||16.43|4.91|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.43||||16.43|8.42|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.43||||16.43|8.42|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.43||||16.43|11.34|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|Self-pay|Self-pay|16.43||||16.43|5.75|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.43||||16.43|4.87|11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.43||||16.43||11.34|4.87
125740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS PIGGYBACK *MINI-BAG*|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.43||||16.43||11.34|4.87
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AARP [1000]|AARP [100000]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AETNA [1015]|AETNA [101529]|0.68||||0.68|0.3|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.68||||0.68|0.2|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.68||||0.68|0.32|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.68||||0.68|0.34|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.68||||0.68|0.34|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.68||||0.68|0.43|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.68||||0.68|0.2|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.68||||0.68|0.37|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.68||||0.68|0.47|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.68||||0.68|0.34|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.68||||0.68|0.3|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.68||||0.68|0.2|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.68||||0.68|0.3|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.68||||0.68|0.2|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.68||||0.68|0.2|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.68||||0.68|0.47|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.68||||0.68|0.2|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|Self-pay|Self-pay|0.68||||0.68|0.24|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.68||||0.68|0.2|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.68||||0.68|0.2|0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.68||||0.68||0.47|0.2
12580|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 0.02 % SOLUTION FOR INHALATION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.68||||0.68||0.47|0.2
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.18||||1.18|0.52|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.18||||1.18|0.35|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.18||||1.18|0.55|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.18||||1.18|0.59|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.18||||1.18|0.59|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.18||||1.18|0.74|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.18||||1.18|0.35|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.18||||1.18|0.65|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.18||||1.18|0.81|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.18||||1.18|0.59|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.18||||1.18|0.52|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.18||||1.18|0.35|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.18||||1.18|0.52|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.18||||1.18|0.35|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.18||||1.18|0.35|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.18||||1.18|0.81|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.18||||1.18|0.35|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|1.18||||1.18|0.41|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.18||||1.18|0.35|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.18||||1.18|0.35|0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.18||||1.18||0.81|0.35
126194|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.18||||1.18||0.81|0.35
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|AARP [1000]|AARP [100000]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|AETNA [1015]|AETNA [101529]|22557.56||||22557.56|14875.2|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22557.56||||22557.56|6688.32|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|BCBS [1155]|BCBS UTHCT [115568]|22557.56||||22557.56|10602.05|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22557.56||||22557.56|0|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22557.56||||22557.56|11278.78|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22557.56||||22557.56|14211.26|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22557.56||||22557.56|6688.32|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|CIGNA [1260]|CIGNA GWH [126023]|22557.56||||22557.56|11278.78|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|22557.56||||22557.56|15564.72|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22557.56||||22557.56|25.44|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22557.56||||22557.56|14875.2|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22557.56||||22557.56|6688.32|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22557.56||||22557.56|14875.2|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22557.56||||22557.56|6688.32|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|22557.56||||22557.56|6688.32|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|22557.56||||22557.56|15564.72|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22557.56||||22557.56|6688.32|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|Self-pay|Self-pay|22557.56||||22557.56|7895.15|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22557.56||||22557.56|6688.32|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22557.56||||22557.56|6688.32|15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22557.56||||22557.56||15564.72|25.44
126219|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VEDOLIZUMAB 300 MG INTRAVENOUS SOLUTION|300 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22557.56||||22557.56||15564.72|25.44
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|AARP [1000]|AARP [100000]|11.96||||11.96|4.5|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.96||||11.96||8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|AETNA [1015]|AETNA [101529]|11.96||||11.96|3.6|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.96||||11.96|3.55|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.96||||11.96||8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.96||||11.96||8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|11.96||||11.96|5.62|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.96||||11.96|0|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.96||||11.96|5.98|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.96||||11.96|7.53|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.96||||11.96|3.55|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.96||||11.96||8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|11.96||||11.96|6.58|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.96||||11.96|8.25|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.96||||11.96|0.04|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.96||||11.96||8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.96||||11.96|3.6|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.96||||11.96|3.55|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.96||||11.96||8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.96||||11.96|3.6|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.96||||11.96|3.55|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.96||||11.96|3.55|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.96||||11.96|8.25|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.96||||11.96|3.55|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|Self-pay|Self-pay|11.96||||11.96|4.19|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.96||||11.96|3.55|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.96||||11.96|3.55|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.96||||11.96|4.5|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.96||||11.96||8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.96||||11.96||8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.96||||11.96|4.5|8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.96||||11.96||8.25|0.04
126225|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 100 MG/ML INTRAMUSCULAR OIL|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.96||||11.96||8.25|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AARP [1000]|AARP [100000]|65.1||||65.1|18|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.1||||65.1||44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AETNA [1015]|AETNA [101529]|65.1||||65.1|14.4|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65.1||||65.1|19.3|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.1||||65.1||44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65.1||||65.1||44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS [1155]|BCBS UTHCT [115568]|65.1||||65.1|30.6|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65.1||||65.1|0|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65.1||||65.1|32.55|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65.1||||65.1|41.01|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65.1||||65.1|19.3|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.1||||65.1||44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|CIGNA [1260]|CIGNA GWH [126023]|65.1||||65.1|35.81|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|65.1||||65.1|44.92|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65.1||||65.1|0.04|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65.1||||65.1||44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65.1||||65.1|14.4|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65.1||||65.1|19.3|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.1||||65.1||44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65.1||||65.1|14.4|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65.1||||65.1|19.3|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|65.1||||65.1|19.3|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|65.1||||65.1|44.92|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65.1||||65.1|19.3|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|Self-pay|Self-pay|65.1||||65.1|22.78|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65.1||||65.1|19.3|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65.1||||65.1|19.3|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65.1||||65.1|18|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65.1||||65.1||44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65.1||||65.1||44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65.1||||65.1|18|44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65.1||||65.1||44.92|0.04
126226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR OIL|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65.1||||65.1||44.92|0.04
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|34.1||||34.1|34.1|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.1||||34.1||34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|34.1||||34.1|21.84|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.1||||34.1|10.11|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.1||||34.1||34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.1||||34.1||34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|34.1||||34.1|16.03|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.1||||34.1|0|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.1||||34.1|17.05|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.1||||34.1|21.48|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.1||||34.1|10.11|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.1||||34.1||34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|34.1||||34.1|18.76|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|34.1||||34.1|23.53|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34.1||||34.1|1.06|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.1||||34.1||34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.1||||34.1|21.84|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.1||||34.1|10.11|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.1||||34.1||34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.1||||34.1|21.84|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.1||||34.1|10.11|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|34.1||||34.1|10.11|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|34.1||||34.1|23.53|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.1||||34.1|10.11|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|Self-pay|Self-pay|34.1||||34.1|11.93|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34.1||||34.1|10.11|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.1||||34.1|10.11|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.1||||34.1|34.1|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34.1||||34.1||34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34.1||||34.1||34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.1||||34.1|34.1|34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.1||||34.1||34.1|1.06
126504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL (PF) 1 MG/ML (1 ML) INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.1||||34.1||34.1|1.06
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|56.69||||56.69|25|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56.69||||56.69|16.81|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|56.69||||56.69|26.64|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56.69||||56.69|28.35|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56.69||||56.69|28.35|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56.69||||56.69|35.71|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56.69||||56.69|16.81|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|56.69||||56.69|31.18|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|56.69||||56.69|39.12|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|56.69||||56.69|28.35|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56.69||||56.69|25|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56.69||||56.69|16.81|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56.69||||56.69|25|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|56.69||||56.69|16.81|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|56.69||||56.69|16.81|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|56.69||||56.69|39.12|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56.69||||56.69|16.81|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|56.69||||56.69|19.84|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|56.69||||56.69|16.81|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56.69||||56.69|16.81|39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56.69||||56.69||39.12|16.81
126630|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMPAGLIFLOZIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|56.69||||56.69||39.12|16.81
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|AARP [1000]|AARP [100000]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|AETNA [1015]|AETNA [101529]|3.89||||3.89|1.72|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.89||||3.89|1.15|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|BCBS [1155]|BCBS UTHCT [115568]|3.89||||3.89|1.83|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.89||||3.89|1.95|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.89||||3.89|1.95|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.89||||3.89|2.45|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.89||||3.89|1.15|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|CIGNA [1260]|CIGNA GWH [126023]|3.89||||3.89|2.14|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.89||||3.89|2.68|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.89||||3.89|1.95|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.89||||3.89|1.72|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.89||||3.89|1.15|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.89||||3.89|1.72|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.89||||3.89|1.15|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.89||||3.89|1.15|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.89||||3.89|2.68|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.89||||3.89|1.15|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|Self-pay|Self-pay|3.89||||3.89|1.36|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.89||||3.89|1.15|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.89||||3.89|1.15|2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.89||||3.89||2.68|1.15
126845|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM PHOSPHATES 9.5 GRAM-3.5 GRAM/59 ML ENEMA|66 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.89||||3.89||2.68|1.15
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|AARP [1000]|AARP [100000]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|189.45||||189.45|83.55|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189.45||||189.45|56.17|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|189.45||||189.45|89.04|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189.45||||189.45|0|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189.45||||189.45|94.73|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189.45||||189.45|119.35|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189.45||||189.45|56.17|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|189.45||||189.45|104.2|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|189.45||||189.45|130.72|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189.45||||189.45|175.95|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189.45||||189.45|83.55|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189.45||||189.45|56.17|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189.45||||189.45|83.55|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189.45||||189.45|56.17|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|189.45||||189.45|56.17|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|189.45||||189.45|130.72|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189.45||||189.45|56.17|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|Self-pay|Self-pay|189.45||||189.45|66.31|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189.45||||189.45|56.17|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189.45||||189.45|56.17|175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189.45||||189.45||175.95|56.17
126851|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189.45||||189.45||175.95|56.17
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|76.27||||76.27|33.64|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76.27||||76.27|22.61|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|76.27||||76.27|35.85|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76.27||||76.27|0|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76.27||||76.27|38.14|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76.27||||76.27|48.05|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76.27||||76.27|22.61|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|76.27||||76.27|41.95|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|76.27||||76.27|52.63|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|76.27||||76.27|35.26|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76.27||||76.27|33.64|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76.27||||76.27|22.61|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76.27||||76.27|33.64|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76.27||||76.27|22.61|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|76.27||||76.27|22.61|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|76.27||||76.27|52.63|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76.27||||76.27|22.61|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|76.27||||76.27|26.69|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|76.27||||76.27|22.61|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76.27||||76.27|22.61|52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76.27||||76.27||52.63|22.61
126911|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 10 MCG/0.5 ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76.27||||76.27||52.63|22.61
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|AARP [1000]|AARP [100000]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|AETNA [1015]|AETNA [101529]|189.45||||189.45|83.55|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189.45||||189.45|56.17|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|189.45||||189.45|89.04|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189.45||||189.45|0|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189.45||||189.45|94.73|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189.45||||189.45|119.35|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189.45||||189.45|56.17|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|189.45||||189.45|104.2|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|189.45||||189.45|130.72|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189.45||||189.45|175.95|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189.45||||189.45|83.55|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189.45||||189.45|56.17|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189.45||||189.45|83.55|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189.45||||189.45|56.17|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|189.45||||189.45|56.17|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|189.45||||189.45|130.72|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189.45||||189.45|56.17|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|Self-pay|Self-pay|189.45||||189.45|66.31|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189.45||||189.45|56.17|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189.45||||189.45|56.17|175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189.45||||189.45||175.95|56.17
126921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS B VIRUS VACCINE RECOMB (PF) 20 MCG/ML INTRAMUSCULAR SUSP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189.45||||189.45||175.95|56.17
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|AARP [1000]|AARP [100000]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|226.31||||226.31|99.8|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|226.31||||226.31|67.1|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|226.31||||226.31|106.37|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|226.31||||226.31|0|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|226.31||||226.31|113.16|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|226.31||||226.31|142.58|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|226.31||||226.31|67.1|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|226.31||||226.31|124.47|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|226.31||||226.31|156.15|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|226.31||||226.31|75.88|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|226.31||||226.31|99.8|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|226.31||||226.31|67.1|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|226.31||||226.31|99.8|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|226.31||||226.31|67.1|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|226.31||||226.31|67.1|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|226.31||||226.31|156.15|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|226.31||||226.31|67.1|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|Self-pay|Self-pay|226.31||||226.31|79.21|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|226.31||||226.31|67.1|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|226.31||||226.31|67.1|156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|226.31||||226.31||156.15|67.1
127052|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VACCINE (PF) 1,440 ELISA UNIT/ML INTRAMUSCULAR SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|226.31||||226.31||156.15|67.1
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|AARP [1000]|AARP [100000]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|343.65||||343.65|151.55|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|343.65||||343.65|101.89|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|343.65||||343.65|161.52|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|343.65||||343.65|171.83|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|343.65||||343.65|171.83|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|343.65||||343.65|216.5|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|343.65||||343.65|101.89|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|343.65||||343.65|189.01|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|343.65||||343.65|237.12|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|343.65||||343.65|171.83|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|343.65||||343.65|151.55|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|343.65||||343.65|101.89|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|343.65||||343.65|151.55|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|343.65||||343.65|101.89|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|343.65||||343.65|101.89|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|343.65||||343.65|237.12|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|343.65||||343.65|101.89|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|Self-pay|Self-pay|343.65||||343.65|120.28|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|343.65||||343.65|101.89|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|343.65||||343.65|101.89|237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|343.65||||343.65||237.12|101.89
127255|ERX|0250 - PHARMACY-GENERAL|HEPATITIS A AND B VIRUS VACCINE(PF)720 ELISA UNIT-20 MCG/ML IM SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|343.65||||343.65||237.12|101.89
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.66||||0.66|0.29|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.66||||0.66|0.2|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.66||||0.66|0.31|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.66||||0.66|0.33|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.66||||0.66|0.33|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.66||||0.66|0.42|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.66||||0.66|0.2|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.66||||0.66|0.36|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.66||||0.66|0.46|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.66||||0.66|0.33|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.66||||0.66|0.29|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.66||||0.66|0.2|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.66||||0.66|0.29|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.66||||0.66|0.2|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.66||||0.66|0.2|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.66||||0.66|0.46|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.66||||0.66|0.2|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.66||||0.66|0.23|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.66||||0.66|0.2|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.66||||0.66|0.2|0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.66||||0.66||0.46|0.2
12729|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.66||||0.66||0.46|0.2
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|553.35||||553.35|244.03|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|553.35||||553.35|164.07|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|553.35||||553.35|260.07|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|553.35||||553.35|0|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|553.35||||553.35|276.68|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|553.35||||553.35|348.61|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|553.35||||553.35|164.07|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|553.35||||553.35|276.68|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|553.35||||553.35|381.81|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|553.35||||553.35|276.68|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|553.35||||553.35|244.03|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|553.35||||553.35|164.07|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|553.35||||553.35|244.03|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|553.35||||553.35|164.07|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|553.35||||553.35|164.07|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|553.35||||553.35|381.81|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|553.35||||553.35|164.07|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|553.35||||553.35|193.67|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|553.35||||553.35|164.07|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|553.35||||553.35|164.07|381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|553.35||||553.35||381.81|164.07
127348|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOCOCCAL B VAC,4-CMP 50 MCG-50 MCG-50 MCG-25 MCG/0.5ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|553.35||||553.35||381.81|164.07
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AARP [1000]|AARP [100000]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AETNA [1015]|AETNA [101529]|232.65||||232.65|102.6|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|232.65||||232.65|68.98|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BCBS UTHCT [115568]|232.65||||232.65|109.35|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|232.65||||232.65|116.33|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|232.65||||232.65|116.33|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|232.65||||232.65|146.57|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|232.65||||232.65|68.98|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|CIGNA [1260]|CIGNA GWH [126023]|232.65||||232.65|127.96|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|232.65||||232.65|160.53|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|232.65||||232.65|116.33|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|232.65||||232.65|102.6|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|232.65||||232.65|68.98|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|232.65||||232.65|102.6|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|232.65||||232.65|68.98|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|232.65||||232.65|68.98|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|232.65||||232.65|160.53|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|232.65||||232.65|68.98|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|Self-pay|Self-pay|232.65||||232.65|81.43|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|232.65||||232.65|68.98|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|232.65||||232.65|68.98|160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|232.65||||232.65||160.53|68.98
127350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|UMECLIDINIUM 62.5 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|232.65||||232.65||160.53|68.98
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AARP [1000]|AARP [100000]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AETNA [1015]|AETNA [101529]|266.35||||266.35|117.46|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|266.35||||266.35|78.97|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BCBS UTHCT [115568]|266.35||||266.35|125.18|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|266.35||||266.35|133.18|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|266.35||||266.35|133.18|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|266.35||||266.35|167.8|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|266.35||||266.35|78.97|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|CIGNA [1260]|CIGNA GWH [126023]|266.35||||266.35|146.49|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|266.35||||266.35|183.78|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|266.35||||266.35|133.18|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|266.35||||266.35|117.46|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|266.35||||266.35|78.97|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|266.35||||266.35|117.46|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|266.35||||266.35|78.97|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|266.35||||266.35|78.97|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|266.35||||266.35|183.78|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|266.35||||266.35|78.97|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|Self-pay|Self-pay|266.35||||266.35|93.22|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|266.35||||266.35|78.97|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|266.35||||266.35|78.97|183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|266.35||||266.35||183.78|78.97
127374|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 100 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|266.35||||266.35||183.78|78.97
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AARP [1000]|AARP [100000]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AETNA [1015]|AETNA [101529]|356.62||||356.62|157.27|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|356.62||||356.62|105.74|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BCBS UTHCT [115568]|356.62||||356.62|167.61|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|356.62||||356.62|178.31|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|356.62||||356.62|178.31|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|356.62||||356.62|224.67|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|356.62||||356.62|105.74|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|CIGNA [1260]|CIGNA GWH [126023]|356.62||||356.62|196.14|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|356.62||||356.62|246.07|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|356.62||||356.62|178.31|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|356.62||||356.62|157.27|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|356.62||||356.62|105.74|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|356.62||||356.62|157.27|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|356.62||||356.62|105.74|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|356.62||||356.62|105.74|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|356.62||||356.62|246.07|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|356.62||||356.62|105.74|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|Self-pay|Self-pay|356.62||||356.62|124.82|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|356.62||||356.62|105.74|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|356.62||||356.62|105.74|246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|356.62||||356.62||246.07|105.74
127375|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE FUROATE 200 MCG/ACTUATION BLISTER POWDER FOR INHALATION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|356.62||||356.62||246.07|105.74
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AARP [1000]|AARP [100000]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AETNA [1015]|AETNA [101529]|15.41||||15.41|6.8|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.41||||15.41|4.57|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|BCBS [1155]|BCBS UTHCT [115568]|15.41||||15.41|7.24|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.41||||15.41|7.71|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.41||||15.41|7.71|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.41||||15.41|9.71|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.41||||15.41|4.57|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|CIGNA [1260]|CIGNA GWH [126023]|15.41||||15.41|8.48|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.41||||15.41|10.63|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.41||||15.41|7.71|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.41||||15.41|6.8|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.41||||15.41|4.57|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.41||||15.41|6.8|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.41||||15.41|4.57|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.41||||15.41|4.57|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.41||||15.41|10.63|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.41||||15.41|4.57|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|Self-pay|Self-pay|15.41||||15.41|5.39|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.41||||15.41|4.57|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.41||||15.41|4.57|10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.41||||15.41||10.63|4.57
12748|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 60 % (W/V) ORAL SUSPENSION|355 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.41||||15.41||10.63|4.57
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|217.94||||217.94|96.11|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217.94||||217.94|64.62|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|217.94||||217.94|102.43|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217.94||||217.94|108.97|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217.94||||217.94|108.97|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217.94||||217.94|137.3|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217.94||||217.94|64.62|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|217.94||||217.94|119.87|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|217.94||||217.94|150.38|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|217.94||||217.94|108.97|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217.94||||217.94|96.11|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217.94||||217.94|64.62|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217.94||||217.94|96.11|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217.94||||217.94|64.62|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|217.94||||217.94|64.62|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|217.94||||217.94|150.38|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217.94||||217.94|64.62|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|Self-pay|Self-pay|217.94||||217.94|76.28|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|217.94||||217.94|64.62|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217.94||||217.94|64.62|150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217.94||||217.94||150.38|64.62
127552|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARUNAVIR 800 MG-COBICISTAT 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217.94||||217.94||150.38|64.62
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|485.46||||485.46|214.09|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|485.46||||485.46|143.94|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|485.46||||485.46|228.17|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|485.46||||485.46|242.73|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|485.46||||485.46|242.73|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|485.46||||485.46|305.84|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|485.46||||485.46|143.94|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|485.46||||485.46|267|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|485.46||||485.46|334.97|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|485.46||||485.46|242.73|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|485.46||||485.46|214.09|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|485.46||||485.46|143.94|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|485.46||||485.46|214.09|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|485.46||||485.46|143.94|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|485.46||||485.46|143.94|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|485.46||||485.46|334.97|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|485.46||||485.46|143.94|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|Self-pay|Self-pay|485.46||||485.46|169.91|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|485.46||||485.46|143.94|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|485.46||||485.46|143.94|334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|485.46||||485.46||334.97|143.94
127603|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|N.MENINGITIDIS GROUP B,LIPID FHBP 120 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|485.46||||485.46||334.97|143.94
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|45.39||||45.39|20.02|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45.39||||45.39|13.46|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|45.39||||45.39|21.33|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45.39||||45.39|22.7|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45.39||||45.39|22.7|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45.39||||45.39|28.6|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45.39||||45.39|13.46|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|45.39||||45.39|24.96|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|45.39||||45.39|31.32|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|45.39||||45.39|22.7|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45.39||||45.39|20.02|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45.39||||45.39|13.46|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45.39||||45.39|20.02|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45.39||||45.39|13.46|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|45.39||||45.39|13.46|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|45.39||||45.39|31.32|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45.39||||45.39|13.46|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|45.39||||45.39|15.89|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|45.39||||45.39|13.46|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45.39||||45.39|13.46|31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45.39||||45.39||31.32|13.46
127665|ERX|0250 - PHARMACY-GENERAL|POTASSIUM PHOSPHATES-MBASIC AND DIBASIC 3 MMOL/ML INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45.39||||45.39||31.32|13.46
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|95.23||||95.23|42|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95.23||||95.23|28.24|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|95.23||||95.23|44.76|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|95.23||||95.23|47.62|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|95.23||||95.23|47.62|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|95.23||||95.23|59.99|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|95.23||||95.23|28.24|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|95.23||||95.23|52.38|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|95.23||||95.23|65.71|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|95.23||||95.23|47.62|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95.23||||95.23|42|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95.23||||95.23|28.24|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95.23||||95.23|42|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|95.23||||95.23|28.24|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|95.23||||95.23|28.24|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|95.23||||95.23|65.71|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95.23||||95.23|28.24|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|95.23||||95.23|33.33|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|95.23||||95.23|28.24|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|95.23||||95.23|28.24|65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95.23||||95.23||65.71|28.24
127668|ERX|0250 - PHARMACY-GENERAL|PYRIDOSTIGMINE BROMIDE 5 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|95.23||||95.23||65.71|28.24
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|AARP [1000]|AARP [100000]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|AETNA [1015]|AETNA [101529]|783.85||||783.85|345.68|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|783.85||||783.85|232.41|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|783.85||||783.85|368.41|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|783.85||||783.85|391.93|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|783.85||||783.85|391.93|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|783.85||||783.85|493.83|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|783.85||||783.85|232.41|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|783.85||||783.85|431.12|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|783.85||||783.85|540.86|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|783.85||||783.85|391.93|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|783.85||||783.85|345.68|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|783.85||||783.85|232.41|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|783.85||||783.85|345.68|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|783.85||||783.85|232.41|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|783.85||||783.85|232.41|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|783.85||||783.85|540.86|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|783.85||||783.85|232.41|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|Self-pay|Self-pay|783.85||||783.85|274.35|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|783.85||||783.85|232.41|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|783.85||||783.85|232.41|540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|783.85||||783.85||540.86|232.41
127765|ERX|0250 - PHARMACY-GENERAL|HUMAN PAPILLOMAVIRUS VACCINE,9-VALENT (PF) 0.5 ML IM SUSPENSION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|783.85||||783.85||540.86|232.41
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|3502.67||||3502.67|1167.2|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3502.67||||3502.67|1166.07|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|3502.67||||3502.67|2738.88|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3502.67||||3502.67|1038.54|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3502.67||||3502.67|1154.52|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3502.67||||3502.67|1154.52|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|3502.67||||3502.67|1646.25|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3502.67||||3502.67|0|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3502.67||||3502.67|1751.34|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3502.67||||3502.67|2206.68|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3502.67||||3502.67|1038.54|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3502.67||||3502.67|1154.52|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|3502.67||||3502.67|1751.34|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3502.67||||3502.67|2416.84|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3502.67||||3502.67|35.68|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3502.67||||3502.67|1154.52|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3502.67||||3502.67|2738.88|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3502.67||||3502.67|1038.54|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3502.67||||3502.67|1154.52|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3502.67||||3502.67|2738.88|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3502.67||||3502.67|1038.54|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3502.67||||3502.67|1038.54|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3502.67||||3502.67|2416.84|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3502.67||||3502.67|1038.54|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|3502.67||||3502.67|1225.93|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3502.67||||3502.67|1038.54|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3502.67||||3502.67|1038.54|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3502.67||||3502.67|1167.2|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3502.67||||3502.67|1154.52|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3502.67||||3502.67|1154.52|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3502.67||||3502.67|1167.2|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3502.67||||3502.67|1154.52|2738.88|35.68
127843|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 40 MG/4 ML INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3502.67||||3502.67|2309.04|2738.88|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|8756.64||||8756.64|4378.32|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8756.64||||8756.64|2915.16|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|8756.64||||8756.64|6847.2|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8756.64||||8756.64|2596.34|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8756.64||||8756.64|2886.3|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8756.64||||8756.64|2886.3|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|8756.64||||8756.64|4115.62|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8756.64||||8756.64|0|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8756.64||||8756.64|4378.32|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8756.64||||8756.64|5516.68|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8756.64||||8756.64|2596.34|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8756.64||||8756.64|2886.3|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|8756.64||||8756.64|4378.32|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8756.64||||8756.64|6042.08|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8756.64||||8756.64|35.68|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8756.64||||8756.64|2886.3|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8756.64||||8756.64|6847.2|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8756.64||||8756.64|2596.34|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8756.64||||8756.64|2886.3|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8756.64||||8756.64|6847.2|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8756.64||||8756.64|2596.34|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8756.64||||8756.64|2596.34|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8756.64||||8756.64|6042.08|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8756.64||||8756.64|2596.34|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|8756.64||||8756.64|3064.82|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8756.64||||8756.64|2596.34|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8756.64||||8756.64|2596.34|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8756.64||||8756.64|4378.32|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8756.64||||8756.64|2886.3|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8756.64||||8756.64|2886.3|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8756.64||||8756.64|4378.32|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8756.64||||8756.64|2886.3|6847.2|35.68
127844|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 100 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8756.64||||8756.64|5772.6|6847.2|35.68
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|15916.52||||15916.52|7958.26|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15916.52||||15916.52|5328.15|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|15916.52||||15916.52|12223.2|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15916.52||||15916.52|4719.25|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15916.52||||15916.52|5275.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15916.52||||15916.52|5275.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|15916.52||||15916.52|7480.76|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15916.52||||15916.52|0|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15916.52||||15916.52|7958.26|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15916.52||||15916.52|10027.41|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15916.52||||15916.52|4719.25|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15916.52||||15916.52|5275.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|15916.52||||15916.52|7958.26|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15916.52||||15916.52|10982.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15916.52||||15916.52|63.31|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15916.52||||15916.52|5275.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15916.52||||15916.52|12223.2|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15916.52||||15916.52|4719.25|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15916.52||||15916.52|5275.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15916.52||||15916.52|12223.2|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15916.52||||15916.52|4719.25|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15916.52||||15916.52|4719.25|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15916.52||||15916.52|10982.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15916.52||||15916.52|4719.25|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|15916.52||||15916.52|5570.78|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15916.52||||15916.52|4719.25|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15916.52||||15916.52|4719.25|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15916.52||||15916.52|7958.26|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15916.52||||15916.52|5275.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15916.52||||15916.52|5275.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15916.52||||15916.52|7958.26|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15916.52||||15916.52|5275.4|12223.2|63.31
127964|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMBROLIZUMAB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15916.52||||15916.52|10550.8|12223.2|63.31
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|66.02||||66.02|29.11|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66.02||||66.02|19.57|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|66.02||||66.02|31.03|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66.02||||66.02|33.01|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66.02||||66.02|33.01|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66.02||||66.02|41.59|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66.02||||66.02|19.57|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|66.02||||66.02|36.31|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|66.02||||66.02|45.55|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66.02||||66.02|33.01|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.02||||66.02|29.11|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66.02||||66.02|19.57|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66.02||||66.02|29.11|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66.02||||66.02|19.57|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|66.02||||66.02|19.57|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|66.02||||66.02|45.55|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66.02||||66.02|19.57|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|66.02||||66.02|23.11|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66.02||||66.02|19.57|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66.02||||66.02|19.57|45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66.02||||66.02||45.55|19.57
128147|ERX|0250 - PHARMACY-GENERAL|SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66.02||||66.02||45.55|19.57
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AARP [1000]|AARP [100000]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AETNA [1015]|AETNA [101529]|1112.32||||1112.32|882.14|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1112.32||||1112.32|329.8|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS [1155]|BCBS UTHCT [115568]|1112.32||||1112.32|522.79|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1112.32||||1112.32|0|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1112.32||||1112.32|556.16|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1112.32||||1112.32|700.76|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1112.32||||1112.32|329.8|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|CIGNA [1260]|CIGNA GWH [126023]|1112.32||||1112.32|556.16|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1112.32||||1112.32|767.5|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1112.32||||1112.32|115.35|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1112.32||||1112.32|882.14|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1112.32||||1112.32|329.8|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1112.32||||1112.32|882.14|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1112.32||||1112.32|329.8|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|1112.32||||1112.32|329.8|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1112.32||||1112.32|767.5|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1112.32||||1112.32|329.8|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|Self-pay|Self-pay|1112.32||||1112.32|389.31|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1112.32||||1112.32|329.8|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1112.32||||1112.32|329.8|882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1112.32||||1112.32||882.14|115.35
128163|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME-AVIBACTAM 2.5 GRAM INTRAVENOUS SOLUTION|2.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1112.32||||1112.32||882.14|115.35
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|27.1||||27.1|11.95|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.1||||27.1|8.04|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|27.1||||27.1|12.74|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.1||||27.1|13.55|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.1||||27.1|13.55|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.1||||27.1|17.07|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.1||||27.1|8.04|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|27.1||||27.1|14.91|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.1||||27.1|18.7|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.1||||27.1|13.55|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.1||||27.1|11.95|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.1||||27.1|8.04|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.1||||27.1|11.95|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.1||||27.1|8.04|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.1||||27.1|8.04|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.1||||27.1|18.7|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.1||||27.1|8.04|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|27.1||||27.1|9.48|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.1||||27.1|8.04|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.1||||27.1|8.04|18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.1||||27.1||18.7|8.04
128328|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 1 MG/ML INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.1||||27.1||18.7|8.04
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|3.03||||3.03|1.34|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.03||||3.03|0.9|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.03||||3.03|1.42|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.03||||3.03|1.52|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.03||||3.03|1.52|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.03||||3.03|1.91|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.03||||3.03|0.9|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.03||||3.03|1.67|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.03||||3.03|2.09|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.03||||3.03|1.52|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.03||||3.03|1.34|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.03||||3.03|0.9|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.03||||3.03|1.34|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.03||||3.03|0.9|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.03||||3.03|0.9|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.03||||3.03|2.09|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.03||||3.03|0.9|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|3.03||||3.03|1.06|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.03||||3.03|0.9|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.03||||3.03|0.9|2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.03||||3.03||2.09|0.9
128434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.03||||3.03||2.09|0.9
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|207.7||||207.7|91.6|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|207.7||||207.7|61.58|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|207.7||||207.7|97.62|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|207.7||||207.7|103.85|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|207.7||||207.7|103.85|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|207.7||||207.7|130.85|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|207.7||||207.7|61.58|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|207.7||||207.7|114.24|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|207.7||||207.7|143.31|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|207.7||||207.7|103.85|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|207.7||||207.7|91.6|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|207.7||||207.7|61.58|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|207.7||||207.7|91.6|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|207.7||||207.7|61.58|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|207.7||||207.7|61.58|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|207.7||||207.7|143.31|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|207.7||||207.7|61.58|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|207.7||||207.7|72.69|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|207.7||||207.7|61.58|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|207.7||||207.7|61.58|143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|207.7||||207.7||143.31|61.58
128452|ERX|0250 - PHARMACY-GENERAL|PARENTERAL AMINO ACID 10 % NO.5 (PEDIATRIC) INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|207.7||||207.7||143.31|61.58
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AARP [1000]|AARP [100000]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AETNA [1015]|AETNA [101529]|19.84||||19.84|8.75|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.84||||19.84|5.88|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|19.84||||19.84|9.32|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.84||||19.84|9.92|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.84||||19.84|9.92|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.84||||19.84|12.5|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.84||||19.84|5.88|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|19.84||||19.84|10.91|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.84||||19.84|13.69|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.84||||19.84|9.92|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.84||||19.84|8.75|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.84||||19.84|5.88|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.84||||19.84|8.75|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.84||||19.84|5.88|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.84||||19.84|5.88|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.84||||19.84|13.69|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.84||||19.84|5.88|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|Self-pay|Self-pay|19.84||||19.84|6.94|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.84||||19.84|5.88|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.84||||19.84|5.88|13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.84||||19.84||13.69|5.88
128497|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN 100 MG/4 ML ORAL SUSPENSION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.84||||19.84||13.69|5.88
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|AARP [1000]|AARP [100000]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|AETNA [1015]|AETNA [101529]|353.71||||353.71|235.2|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|353.71||||353.71|104.88|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|BCBS [1155]|BCBS UTHCT [115568]|353.71||||353.71|166.24|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|353.71||||353.71|0|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|353.71||||353.71|176.86|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|353.71||||353.71|222.84|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|353.71||||353.71|104.88|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|CIGNA [1260]|CIGNA GWH [126023]|353.71||||353.71|194.54|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|353.71||||353.71|244.06|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|353.71||||353.71|0.15|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|353.71||||353.71|235.2|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|353.71||||353.71|104.88|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|353.71||||353.71|235.2|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|353.71||||353.71|104.88|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|353.71||||353.71|104.88|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|353.71||||353.71|244.06|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|353.71||||353.71|104.88|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|Self-pay|Self-pay|353.71||||353.71|123.8|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|353.71||||353.71|104.88|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|353.71||||353.71|104.88|244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|353.71||||353.71||244.06|0.15
128575|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOLEUCOVORIN CALCIUM 10 MG/ML INTRAVENOUS SOLUTION|175 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|353.71||||353.71||244.06|0.15
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|AARP [1000]|AARP [100000]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|AETNA [1015]|AETNA [101529]|354.15||||354.15|156.18|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|354.15||||354.15|105.01|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|BCBS [1155]|BCBS UTHCT [115568]|354.15||||354.15|166.45|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|354.15||||354.15|177.08|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|354.15||||354.15|177.08|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|354.15||||354.15|223.11|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|354.15||||354.15|105.01|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|CIGNA [1260]|CIGNA GWH [126023]|354.15||||354.15|194.78|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|GROUP PENSION ADMIN [1450]|GPA [145000]|354.15||||354.15|244.36|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|354.15||||354.15|177.08|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|354.15||||354.15|156.18|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|354.15||||354.15|105.01|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|354.15||||354.15|156.18|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|354.15||||354.15|105.01|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|354.15||||354.15|105.01|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|PHCS [1780]|PHCS MULTIPLAN [178000]|354.15||||354.15|244.36|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|354.15||||354.15|105.01|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|Self-pay|Self-pay|354.15||||354.15|123.95|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|354.15||||354.15|105.01|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|354.15||||354.15|105.01|244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|354.15||||354.15||244.36|105.01
12858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CADEXOMER IODINE 0.9 % TOPICAL GEL|40 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|354.15||||354.15||244.36|105.01
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|AARP [1000]|AARP [100000]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|AETNA [1015]|AETNA [101529]|619.57||||619.57|273.23|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|619.57||||619.57|183.7|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|619.57||||619.57|291.2|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|619.57||||619.57|309.79|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|619.57||||619.57|309.79|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|619.57||||619.57|390.33|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|619.57||||619.57|183.7|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|619.57||||619.57|340.76|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|619.57||||619.57|427.5|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|619.57||||619.57|309.79|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|619.57||||619.57|273.23|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|619.57||||619.57|183.7|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|619.57||||619.57|273.23|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|619.57||||619.57|183.7|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|619.57||||619.57|183.7|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|619.57||||619.57|427.5|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|619.57||||619.57|183.7|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|Self-pay|Self-pay|619.57||||619.57|216.85|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|619.57||||619.57|183.7|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|619.57||||619.57|183.7|427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|619.57||||619.57||427.5|183.7
128656|ERX|0250 - PHARMACY-GENERAL|DP(A)T-POLIO-HIB CONJ-TET (PF) 15 LF UNIT-20 MCG-5 LF /0.5 ML IM KIT|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|619.57||||619.57||427.5|183.7
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|AARP [1000]|AARP [100000]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|AETNA [1015]|AETNA [101529]|19.88||||19.88|8.77|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.88||||19.88|5.89|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|BCBS [1155]|BCBS UTHCT [115568]|19.88||||19.88|9.34|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.88||||19.88|9.94|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.88||||19.88|9.94|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.88||||19.88|12.52|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.88||||19.88|5.89|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|CIGNA [1260]|CIGNA GWH [126023]|19.88||||19.88|10.93|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.88||||19.88|13.72|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.88||||19.88|9.94|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.88||||19.88|8.77|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.88||||19.88|5.89|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.88||||19.88|8.77|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.88||||19.88|5.89|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.88||||19.88|5.89|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.88||||19.88|13.72|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.88||||19.88|5.89|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|Self-pay|Self-pay|19.88||||19.88|6.96|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.88||||19.88|5.89|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.88||||19.88|5.89|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.88||||19.88||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AARP [1000]|AARP [100000]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AETNA [1015]|AETNA [101529]|17.83||||17.83|7.86|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.83||||17.83|5.29|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS [1155]|BCBS UTHCT [115568]|17.83||||17.83|8.38|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.83||||17.83|8.92|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.83||||17.83|8.92|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.83||||17.83|11.23|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.83||||17.83|5.29|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|CIGNA [1260]|CIGNA GWH [126023]|17.83||||17.83|9.81|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.83||||17.83|12.3|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.83||||17.83|8.92|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.83||||17.83|7.86|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.83||||17.83|5.29|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.83||||17.83|7.86|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.83||||17.83|5.29|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.83||||17.83|5.29|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.83||||17.83|12.3|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.83||||17.83|5.29|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|Self-pay|Self-pay|17.83||||17.83|6.24|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.83||||17.83|5.29|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.83||||17.83|5.29|13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.83||||17.83||13.72|5.29
128756|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.83||||17.83||13.72|5.29
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|33.27||||33.27|11.9|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.27||||33.27||25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|33.27||||33.27|25.3|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.27||||33.27|9.86|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.27||||33.27||25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.27||||33.27||25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|33.27||||33.27|15.64|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.27||||33.27|0|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.27||||33.27|16.64|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.27||||33.27|20.96|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.27||||33.27|9.86|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.27||||33.27||25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|33.27||||33.27|18.3|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33.27||||33.27|22.96|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.27||||33.27|6.3|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.27||||33.27||25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.27||||33.27|25.3|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.27||||33.27|9.86|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.27||||33.27||25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.27||||33.27|25.3|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.27||||33.27|9.86|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.27||||33.27|9.86|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33.27||||33.27|22.96|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.27||||33.27|9.86|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|33.27||||33.27|11.64|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.27||||33.27|9.86|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.27||||33.27|9.86|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.27||||33.27|11.9|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.27||||33.27||25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.27||||33.27||25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.27||||33.27|11.9|25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.27||||33.27||25.3|6.3
128758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 2 MG/2 ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.27||||33.27||25.3|6.3
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|AARP [1000]|AARP [100000]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|AETNA [1015]|AETNA [101529]|12.67||||12.67|5.59|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.67||||12.67|3.76|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|BCBS [1155]|BCBS UTHCT [115568]|12.67||||12.67|5.95|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.67||||12.67|6.34|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.67||||12.67|6.34|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.67||||12.67|7.98|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.67||||12.67|3.76|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|CIGNA [1260]|CIGNA GWH [126023]|12.67||||12.67|6.97|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|GROUP PENSION ADMIN [1450]|GPA [145000]|12.67||||12.67|8.74|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.67||||12.67|6.34|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.67||||12.67|5.59|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.67||||12.67|3.76|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.67||||12.67|5.59|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.67||||12.67|3.76|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.67||||12.67|3.76|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|PHCS [1780]|PHCS MULTIPLAN [178000]|12.67||||12.67|8.74|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.67||||12.67|3.76|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|Self-pay|Self-pay|12.67||||12.67|4.43|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.67||||12.67|3.76|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.67||||12.67|3.76|8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.67||||12.67||8.74|3.76
128760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LANOLIN ALCOHOLS-MINERAL OIL-W.PETROLATUM-CERESIN TOPICAL CREAM|454 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.67||||12.67||8.74|3.76
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AARP [1000]|AARP [100000]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AETNA [1015]|AETNA [101529]|492.28||||492.28|217.1|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|492.28||||492.28|145.96|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|492.28||||492.28|231.37|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|492.28||||492.28|246.14|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|492.28||||492.28|246.14|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|492.28||||492.28|310.14|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|492.28||||492.28|145.96|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|492.28||||492.28|270.75|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|492.28||||492.28|339.67|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|492.28||||492.28|246.14|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|492.28||||492.28|217.1|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|492.28||||492.28|145.96|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|492.28||||492.28|217.1|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|492.28||||492.28|145.96|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|492.28||||492.28|145.96|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|492.28||||492.28|339.67|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|492.28||||492.28|145.96|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|Self-pay|Self-pay|492.28||||492.28|172.3|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|492.28||||492.28|145.96|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|492.28||||492.28|145.96|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|492.28||||492.28||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|26.57||||26.57|11.72|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.57||||26.57|7.88|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|26.57||||26.57|12.49|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.57||||26.57|13.29|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.57||||26.57|13.29|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.57||||26.57|16.74|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.57||||26.57|7.88|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|26.57||||26.57|14.61|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|26.57||||26.57|18.33|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|26.57||||26.57|13.29|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.57||||26.57|11.72|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.57||||26.57|7.88|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.57||||26.57|11.72|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.57||||26.57|7.88|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|26.57||||26.57|7.88|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|26.57||||26.57|18.33|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.57||||26.57|7.88|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|26.57||||26.57|9.3|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|26.57||||26.57|7.88|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.57||||26.57|7.88|339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.57||||26.57||339.67|7.88
12886|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 250 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.57||||26.57||339.67|7.88
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|17.05||||17.05|7.52|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.05||||17.05|5.06|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|17.05||||17.05|8.01|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.05||||17.05|8.53|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.05||||17.05|8.53|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.05||||17.05|10.74|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.05||||17.05|5.06|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|17.05||||17.05|9.38|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.05||||17.05|11.76|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.05||||17.05|8.53|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.05||||17.05|7.52|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.05||||17.05|5.06|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.05||||17.05|7.52|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.05||||17.05|5.06|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.05||||17.05|5.06|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.05||||17.05|11.76|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.05||||17.05|5.06|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|17.05||||17.05|5.97|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.05||||17.05|5.06|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.05||||17.05|5.06|11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.05||||17.05||11.76|5.06
128924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.05||||17.05||11.76|5.06
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AARP [1000]|AARP [100000]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AETNA [1015]|AETNA [101529]|83.7||||83.7|36.91|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83.7||||83.7|24.82|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS [1155]|BCBS UTHCT [115568]|83.7||||83.7|39.34|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83.7||||83.7|41.85|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83.7||||83.7|41.85|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83.7||||83.7|52.73|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83.7||||83.7|24.82|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|CIGNA [1260]|CIGNA GWH [126023]|83.7||||83.7|46.04|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|83.7||||83.7|57.75|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|83.7||||83.7|41.85|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83.7||||83.7|36.91|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83.7||||83.7|24.82|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83.7||||83.7|36.91|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83.7||||83.7|24.82|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|83.7||||83.7|24.82|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|83.7||||83.7|57.75|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83.7||||83.7|24.82|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|Self-pay|Self-pay|83.7||||83.7|29.29|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|83.7||||83.7|24.82|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83.7||||83.7|24.82|57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83.7||||83.7||57.75|24.82
129082|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 4 MG/250 ML (16 MCG/ML) IN DEXTROSE 5 % IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83.7||||83.7||57.75|24.82
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.97||||1.97|0.87|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.97||||1.97|0.58|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.97||||1.97|0.93|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.97||||1.97|0.99|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.97||||1.97|0.99|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.97||||1.97|1.24|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.97||||1.97|0.58|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.97||||1.97|1.08|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.97||||1.97|1.36|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.97||||1.97|0.99|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.97||||1.97|0.87|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.97||||1.97|0.58|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.97||||1.97|0.87|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.97||||1.97|0.58|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.97||||1.97|0.58|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.97||||1.97|1.36|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.97||||1.97|0.58|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|Self-pay|Self-pay|1.97||||1.97|0.69|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.97||||1.97|0.58|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.97||||1.97|0.58|1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.97||||1.97||1.36|0.58
129143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THYROID (PORK) 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.97||||1.97||1.36|0.58
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AARP [1000]|AARP [100000]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1||||1|0.44|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1||||1|0.3|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1||||1|0.47|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1||||1|0.5|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1||||1|0.5|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1||||1|0.63|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1||||1|0.3|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1||||1|0.55|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1||||1|0.69|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1||||1|0.5|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1||||1|0.44|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1||||1|0.3|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1||||1|0.44|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1||||1|0.3|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1||||1|0.3|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1||||1|0.69|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1||||1|0.3|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|Self-pay|Self-pay|1||||1|0.35|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1||||1|0.3|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1||||1|0.3|0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1||||1||0.69|0.3
129217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTOBACILLUS ACIDOPH-L.BULGARICUS 1 MILLION CELL TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1||||1||0.69|0.3
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|AARP [1000]|AARP [100000]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|AETNA [1015]|AETNA [101529]|5.64||||5.64|2.49|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.64||||5.64|1.67|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|BCBS [1155]|BCBS UTHCT [115568]|5.64||||5.64|2.65|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.64||||5.64|2.82|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.64||||5.64|2.82|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.64||||5.64|3.55|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.64||||5.64|1.67|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|CIGNA [1260]|CIGNA GWH [126023]|5.64||||5.64|3.1|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.64||||5.64|3.89|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.64||||5.64|2.82|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.64||||5.64|2.49|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.64||||5.64|1.67|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.64||||5.64|2.49|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.64||||5.64|1.67|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.64||||5.64|1.67|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.64||||5.64|3.89|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.64||||5.64|1.67|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|Self-pay|Self-pay|5.64||||5.64|1.97|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.64||||5.64|1.67|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.64||||5.64|1.67|3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.64||||5.64||3.89|1.67
129287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SOLUTION|10.15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.64||||5.64||3.89|1.67
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AARP [1000]|AARP [100000]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AETNA [1015]|AETNA [101529]|6.3||||6.3|2.78|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.3||||6.3|1.87|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS [1155]|BCBS UTHCT [115568]|6.3||||6.3|2.96|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.3||||6.3|3.15|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.3||||6.3|3.15|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.3||||6.3|3.97|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.3||||6.3|1.87|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|CIGNA [1260]|CIGNA GWH [126023]|6.3||||6.3|3.47|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|6.3||||6.3|4.35|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.3||||6.3|3.15|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.3||||6.3|2.78|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.3||||6.3|1.87|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.3||||6.3|2.78|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.3||||6.3|1.87|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.3||||6.3|1.87|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|6.3||||6.3|4.35|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.3||||6.3|1.87|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|Self-pay|Self-pay|6.3||||6.3|2.2|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.3||||6.3|1.87|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.3||||6.3|1.87|4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.3||||6.3||4.35|1.87
129288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 650 MG/20.3 ML ORAL SOLUTION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.3||||6.3||4.35|1.87
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AARP [1000]|AARP [100000]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|7.13||||7.13|1.42|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.13||||7.13|2.11|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|7.13||||7.13|3.35|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.13||||7.13|0|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.13||||7.13|3.57|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.13||||7.13|4.49|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.13||||7.13|2.11|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|7.13||||7.13|3.92|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|7.13||||7.13|4.92|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.13||||7.13|0.75|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.13||||7.13|1.42|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.13||||7.13|2.11|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.13||||7.13|1.42|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.13||||7.13|2.11|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.13||||7.13|2.11|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|7.13||||7.13|4.92|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.13||||7.13|2.11|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|Self-pay|Self-pay|7.13||||7.13|2.5|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.13||||7.13|2.11|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.13||||7.13|2.11|4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.13||||7.13||4.92|0.75
12933|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 1 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.13||||7.13||4.92|0.75
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|18.75||||18.75|5.86|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.75||||18.75||12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|18.75||||18.75|10.85|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.75||||18.75|5.56|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.75||||18.75||12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.75||||18.75||12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|18.75||||18.75|8.81|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.75||||18.75|0|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.75||||18.75|9.38|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.75||||18.75|11.81|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.75||||18.75|5.56|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.75||||18.75||12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|18.75||||18.75|10.31|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.75||||18.75|12.94|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.75||||18.75|5.48|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.75||||18.75||12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.75||||18.75|10.85|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.75||||18.75|5.56|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.75||||18.75||12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.75||||18.75|10.85|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.75||||18.75|5.56|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.75||||18.75|5.56|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.75||||18.75|12.94|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.75||||18.75|5.56|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|Self-pay|Self-pay|18.75||||18.75|6.56|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.75||||18.75|5.56|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.75||||18.75|5.56|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.75||||18.75|5.86|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.75||||18.75||12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.75||||18.75||12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.75||||18.75|5.86|12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.75||||18.75||12.94|5.48
129396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 40 MG/ML SOLUTION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.75||||18.75||12.94|5.48
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|AARP [1000]|AARP [100000]|30.19||||30.19|14.99|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.19||||30.19||20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|AETNA [1015]|AETNA [101529]|30.19||||30.19|16.13|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.19||||30.19|8.95|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.19||||30.19||20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.19||||30.19||20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|30.19||||30.19|14.19|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.19||||30.19|0|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.19||||30.19|15.1|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.19||||30.19|19.02|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.19||||30.19|8.95|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.19||||30.19||20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|30.19||||30.19|16.6|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|30.19||||30.19|20.83|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.19||||30.19|6.86|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.19||||30.19||20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.19||||30.19|16.13|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.19||||30.19|8.95|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.19||||30.19||20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.19||||30.19|16.13|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.19||||30.19|8.95|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.19||||30.19|8.95|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|30.19||||30.19|20.83|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.19||||30.19|8.95|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|Self-pay|Self-pay|30.19||||30.19|10.57|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.19||||30.19|8.95|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.19||||30.19|8.95|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.19||||30.19|14.99|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.19||||30.19||20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.19||||30.19||20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.19||||30.19|14.99|20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.19||||30.19||20.83|6.86
129397|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE SOD SUCC (PF) 125 MG/2 ML SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.19||||30.19||20.83|6.86
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|AARP [1000]|AARP [100000]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|AETNA [1015]|AETNA [101529]|9601.57||||9601.57|7630.08|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9601.57||||9601.57|2846.87|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|BCBS [1155]|BCBS UTHCT [115568]|9601.57||||9601.57|4512.74|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9601.57||||9601.57|0|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9601.57||||9601.57|4800.79|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9601.57||||9601.57|6048.99|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9601.57||||9601.57|2846.87|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|CIGNA [1260]|CIGNA GWH [126023]|9601.57||||9601.57|4800.79|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|9601.57||||9601.57|6625.08|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9601.57||||9601.57|398.65|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9601.57||||9601.57|7630.08|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9601.57||||9601.57|2846.87|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9601.57||||9601.57|7630.08|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9601.57||||9601.57|2846.87|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|9601.57||||9601.57|2846.87|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|9601.57||||9601.57|6625.08|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9601.57||||9601.57|2846.87|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|Self-pay|Self-pay|9601.57||||9601.57|3360.55|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9601.57||||9601.57|2846.87|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9601.57||||9601.57|2846.87|7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9601.57||||9601.57||7630.08|398.65
129413|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRABECTEDIN 1 MG INTRAVENOUS SOLUTION|1 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9601.57||||9601.57||7630.08|398.65
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AARP [1000]|AARP [100000]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AETNA [1015]|AETNA [101529]|445.03||||445.03|196.26|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|445.03||||445.03|131.95|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS [1155]|BCBS UTHCT [115568]|445.03||||445.03|209.16|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|445.03||||445.03|222.52|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|445.03||||445.03|222.52|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|445.03||||445.03|280.37|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|445.03||||445.03|131.95|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|CIGNA [1260]|CIGNA GWH [126023]|445.03||||445.03|244.77|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|445.03||||445.03|307.07|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|445.03||||445.03|222.52|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|445.03||||445.03|196.26|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|445.03||||445.03|131.95|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|445.03||||445.03|196.26|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|445.03||||445.03|131.95|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|445.03||||445.03|131.95|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|445.03||||445.03|307.07|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|445.03||||445.03|131.95|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|Self-pay|Self-pay|445.03||||445.03|155.76|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|445.03||||445.03|131.95|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|445.03||||445.03|131.95|307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|445.03||||445.03||307.07|131.95
129483|ERX|0250 - PHARMACY-GENERAL|FLUTICASONE FUROATE 200 MCG-VILANTEROL 25 MCG/DOSE INHALATION POWDER|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|445.03||||445.03||307.07|131.95
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|AARP [1000]|AARP [100000]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|AETNA [1015]|AETNA [101529]|431.7||||431.7|190.38|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|431.7||||431.7|128|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|431.7||||431.7|202.9|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|431.7||||431.7|0|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|431.7||||431.7|215.85|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|431.7||||431.7|271.97|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|431.7||||431.7|128|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|431.7||||431.7|237.44|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|431.7||||431.7|297.87|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|431.7||||431.7|215.85|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|431.7||||431.7|190.38|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|431.7||||431.7|128|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|431.7||||431.7|190.38|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|431.7||||431.7|128|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|431.7||||431.7|128|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|431.7||||431.7|297.87|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|431.7||||431.7|128|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|Self-pay|Self-pay|431.7||||431.7|151.09|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|431.7||||431.7|128|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|431.7||||431.7|128|297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|431.7||||431.7||297.87|128
129531|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MENINGOC VAC A,C,Y,W-135 DIP(PF) 10 MCG-5 MCG/0.5 ML INTRAMUSCULAR KIT|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|431.7||||431.7||297.87|128
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|AARP [1000]|AARP [100000]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|AETNA [1015]|AETNA [101529]|150||||150|0|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|150||||150|44.48|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BCBS UTHCT [115568]|150||||150|70.5|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|150||||150|0|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|150||||150|75|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|150||||150|94.5|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|150||||150|44.48|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|CIGNA [1260]|CIGNA GWH [126023]|150||||150|82.5|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|150||||150|103.5|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|150||||150|75|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|150||||150|0|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|150||||150|44.48|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|150||||150|0|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|150||||150|44.48|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|150||||150|44.48|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|150||||150|103.5|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|150||||150|44.48|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|Self-pay|Self-pay|150||||150|52.5|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|150||||150|44.48|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|150||||150|44.48|103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|150||||150||103.5|44.48
129630|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEDRONATE (MDP) PER DOSE UP TO 30MCI|30 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|150||||150||103.5|44.48
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|AARP [1000]|AARP [100000]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|AETNA [1015]|AETNA [101529]|307.4||||307.4|0|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|307.4||||307.4|91.14|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|BCBS [1155]|BCBS UTHCT [115568]|307.4||||307.4|144.48|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|307.4||||307.4|0|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|307.4||||307.4|153.7|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|307.4||||307.4|193.66|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|307.4||||307.4|91.14|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|CIGNA [1260]|CIGNA GWH [126023]|307.4||||307.4|169.07|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|307.4||||307.4|212.11|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|307.4||||307.4|153.7|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|307.4||||307.4|0|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|307.4||||307.4|91.14|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|307.4||||307.4|0|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|307.4||||307.4|91.14|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|307.4||||307.4|91.14|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|307.4||||307.4|212.11|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|307.4||||307.4|91.14|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|Self-pay|Self-pay|307.4||||307.4|107.59|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|307.4||||307.4|91.14|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|307.4||||307.4|91.14|212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|307.4||||307.4||212.11|91.14
129636|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MEBROFENIN (CHOLETEC) PER DOSE UP TO 15 MCI|15 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|307.4||||307.4||212.11|91.14
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|AARP [1000]|AARP [100000]|2912.52||||2912.52|1014.7|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2912.52||||2912.52|878.06|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|AETNA [1015]|AETNA [101529]|2912.52||||2912.52|2240.88|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2912.52||||2912.52|863.56|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2912.52||||2912.52|869.37|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2912.52||||2912.52|869.37|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|BCBS [1155]|BCBS UTHCT [115568]|2912.52||||2912.52|1368.88|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2912.52||||2912.52|0|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2912.52||||2912.52|1456.26|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2912.52||||2912.52|1834.89|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2912.52||||2912.52|863.56|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2912.52||||2912.52|869.37|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|CIGNA [1260]|CIGNA GWH [126023]|2912.52||||2912.52|1456.26|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2912.52||||2912.52|2009.64|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2912.52||||2912.52|114.08|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2912.52||||2912.52|869.37|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2912.52||||2912.52|2240.88|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2912.52||||2912.52|863.56|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2912.52||||2912.52|869.37|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2912.52||||2912.52|2240.88|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2912.52||||2912.52|863.56|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2912.52||||2912.52|863.56|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2912.52||||2912.52|2009.64|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2912.52||||2912.52|863.56|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|Self-pay|Self-pay|2912.52||||2912.52|1019.38|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2912.52||||2912.52|863.56|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2912.52||||2912.52|863.56|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2912.52||||2912.52|1014.7|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2912.52||||2912.52|869.37|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2912.52||||2912.52|869.37|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2912.52||||2912.52|1014.7|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2912.52||||2912.52|869.37|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2912.52||||2912.52|1738.74|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AARP [1000]|AARP [100000]|14562.56||||14562.56|7281.28|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14562.56||||14562.56|4390.32|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AETNA [1015]|AETNA [101529]|14562.56||||14562.56|11204.4|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14562.56||||14562.56|4317.8|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14562.56||||14562.56|4346.85|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14562.56||||14562.56|4346.85|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS [1155]|BCBS UTHCT [115568]|14562.56||||14562.56|6844.4|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14562.56||||14562.56|0|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14562.56||||14562.56|7281.28|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14562.56||||14562.56|9174.41|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14562.56||||14562.56|4317.8|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14562.56||||14562.56|4346.85|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|CIGNA [1260]|CIGNA GWH [126023]|14562.56||||14562.56|7281.28|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14562.56||||14562.56|10048.17|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14562.56||||14562.56|114.08|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14562.56||||14562.56|4346.85|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14562.56||||14562.56|11204.4|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14562.56||||14562.56|4317.8|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14562.56||||14562.56|4346.85|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14562.56||||14562.56|11204.4|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14562.56||||14562.56|4317.8|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14562.56||||14562.56|4317.8|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14562.56||||14562.56|10048.17|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14562.56||||14562.56|4317.8|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|Self-pay|Self-pay|14562.56||||14562.56|5096.9|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14562.56||||14562.56|4317.8|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14562.56||||14562.56|4317.8|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14562.56||||14562.56|7281.28|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14562.56||||14562.56|4346.85|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14562.56||||14562.56|4346.85|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14562.56||||14562.56|7281.28|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14562.56||||14562.56|4346.85|11204.4|114.08
129648|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB 10 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14562.56||||14562.56|8693.7|11204.4|114.08
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AARP [1000]|AARP [100000]|21.08||||21.08|6.44|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.08||||21.08||14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AETNA [1015]|AETNA [101529]|21.08||||21.08|6.14|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.08||||21.08|6.25|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.08||||21.08||14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.08||||21.08||14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS [1155]|BCBS UTHCT [115568]|21.08||||21.08|9.91|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.08||||21.08|0|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.08||||21.08|10.54|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.08||||21.08|13.28|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.08||||21.08|6.25|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.08||||21.08||14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|CIGNA [1260]|CIGNA GWH [126023]|21.08||||21.08|11.59|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.08||||21.08|14.55|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.08||||21.08|0.79|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.08||||21.08||14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.08||||21.08|6.14|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.08||||21.08|6.25|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.08||||21.08||14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.08||||21.08|6.14|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.08||||21.08|6.25|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.08||||21.08|6.25|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.08||||21.08|14.55|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.08||||21.08|6.25|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|Self-pay|Self-pay|21.08||||21.08|7.38|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.08||||21.08|6.25|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.08||||21.08|6.25|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.08||||21.08|6.44|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.08||||21.08||14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.08||||21.08||14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.08||||21.08|6.44|14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.08||||21.08||14.55|0.79
129651|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 2 GRAM/50 ML (4 %) IN WATER INTRAVENOUS PIGGYBACK REPACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.08||||21.08||14.55|0.79
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|AARP [1000]|AARP [100000]|19895.77||||19895.77|9947.89|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19895.77||||19895.77|2243.84|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|AETNA [1015]|AETNA [101529]|19895.77||||19895.77|9137.52|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19895.77||||19895.77|5899.1|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19895.77||||19895.77|2221.63|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19895.77||||19895.77|2221.63|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|BCBS [1155]|BCBS UTHCT [115568]|19895.77||||19895.77|9351.01|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19895.77||||19895.77|0|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19895.77||||19895.77|9947.89|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19895.77||||19895.77|12534.34|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19895.77||||19895.77|5899.1|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19895.77||||19895.77|2221.63|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|CIGNA [1260]|CIGNA GWH [126023]|19895.77||||19895.77|9947.89|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19895.77||||19895.77|13728.08|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19895.77||||19895.77|3849.36|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19895.77||||19895.77|2221.63|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19895.77||||19895.77|9137.52|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19895.77||||19895.77|5899.1|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19895.77||||19895.77|2221.63|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19895.77||||19895.77|9137.52|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19895.77||||19895.77|5899.1|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19895.77||||19895.77|5899.1|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19895.77||||19895.77|13728.08|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19895.77||||19895.77|5899.1|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|Self-pay|Self-pay|19895.77||||19895.77|6963.52|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19895.77||||19895.77|5899.1|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19895.77||||19895.77|5899.1|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19895.77||||19895.77|9947.89|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19895.77||||19895.77|2221.63|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19895.77||||19895.77|2221.63|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19895.77||||19895.77|9947.89|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19895.77||||19895.77|2221.63|13728.08|2221.63
129658|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM 6 MG/0.6 ML (DELIVERABLE) WEARABLE SUBCUTANEOUS INJECTOR|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19895.77||||19895.77|4443.25|13728.08|2221.63
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|AARP [1000]|AARP [100000]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|AETNA [1015]|AETNA [101529]|270||||270|0|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|270||||270|80.06|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|BCBS [1155]|BCBS UTHCT [115568]|270||||270|126.9|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|270||||270|0|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|270||||270|135|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|270||||270|170.1|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|270||||270|80.06|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|CIGNA [1260]|CIGNA GWH [126023]|270||||270|148.5|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|270||||270|186.3|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|270||||270|135|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|270||||270|0|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|270||||270|80.06|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|270||||270|0|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|270||||270|80.06|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|270||||270|80.06|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|270||||270|186.3|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|270||||270|80.06|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|Self-pay|Self-pay|270||||270|94.5|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|270||||270|80.06|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|270||||270|80.06|186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|270||||270||186.3|80.06
129660|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M PYROPHOSPHATE PER DOSE UP TO 25 MCI|25 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|270||||270||186.3|80.06
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|102.62||||102.62|79.9|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102.62||||102.62|30.43|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|102.62||||102.62|48.23|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102.62||||102.62|0|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102.62||||102.62|51.31|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102.62||||102.62|64.65|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102.62||||102.62|30.43|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|102.62||||102.62|56.44|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|102.62||||102.62|70.81|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102.62||||102.62|44.86|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102.62||||102.62|79.9|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102.62||||102.62|30.43|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102.62||||102.62|79.9|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102.62||||102.62|30.43|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|102.62||||102.62|30.43|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|102.62||||102.62|70.81|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102.62||||102.62|30.43|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|102.62||||102.62|35.92|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102.62||||102.62|30.43|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102.62||||102.62|30.43|79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102.62||||102.62||79.9|30.43
129677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CHLORPROMAZINE 25 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102.62||||102.62||79.9|30.43
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|1034.47||||1034.47|354|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1034.47||||1034.47|294.52|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|1034.47||||1034.47|662.4|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1034.47||||1034.47|306.72|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1034.47||||1034.47|291.6|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1034.47||||1034.47|291.6|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|1034.47||||1034.47|486.2|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1034.47||||1034.47|0|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1034.47||||1034.47|517.24|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1034.47||||1034.47|651.72|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1034.47||||1034.47|306.72|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1034.47||||1034.47|291.6|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|1034.47||||1034.47|517.24|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1034.47||||1034.47|713.78|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1034.47||||1034.47|1.18|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1034.47||||1034.47|291.6|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1034.47||||1034.47|662.4|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1034.47||||1034.47|306.72|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1034.47||||1034.47|291.6|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1034.47||||1034.47|662.4|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1034.47||||1034.47|306.72|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1034.47||||1034.47|306.72|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1034.47||||1034.47|713.78|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1034.47||||1034.47|306.72|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|Self-pay|Self-pay|1034.47||||1034.47|362.06|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1034.47||||1034.47|306.72|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1034.47||||1034.47|306.72|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1034.47||||1034.47|354|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1034.47||||1034.47|291.6|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1034.47||||1034.47|291.6|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1034.47||||1034.47|354|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1034.47||||1034.47|291.6|713.78|1.18
129689|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM 300 MCG/0.5 ML INJECTION SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1034.47||||1034.47|583.2|713.78|1.18
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|AARP [1000]|AARP [100000]|88.45||||88.45|31.44|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|88.45||||88.45||88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|AETNA [1015]|AETNA [101529]|88.45||||88.45|88.45|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|88.45||||88.45|26.23|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|88.45||||88.45||88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|88.45||||88.45||88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|88.45||||88.45|41.57|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|88.45||||88.45|0|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|88.45||||88.45|44.23|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|88.45||||88.45|55.72|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|88.45||||88.45|26.23|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|88.45||||88.45||88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|88.45||||88.45|48.65|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|88.45||||88.45|61.03|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|88.45||||88.45|17.69|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|88.45||||88.45||88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|88.45||||88.45|88.45|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|88.45||||88.45|26.23|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|88.45||||88.45||88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|88.45||||88.45|88.45|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|88.45||||88.45|26.23|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|88.45||||88.45|26.23|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|88.45||||88.45|61.03|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|88.45||||88.45|26.23|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|Self-pay|Self-pay|88.45||||88.45|30.96|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|88.45||||88.45|26.23|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|88.45||||88.45|26.23|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|88.45||||88.45|31.44|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|88.45||||88.45||88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|88.45||||88.45||88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|88.45||||88.45|31.44|88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|88.45||||88.45||88.45|17.69
129717|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 250 MG/2 ML SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|88.45||||88.45||88.45|17.69
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AARP [1000]|AARP [100000]|47.81||||47.81|10.48|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|47.81||||47.81||33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AETNA [1015]|AETNA [101529]|47.81||||47.81|33.94|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|47.81||||47.81|14.18|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|47.81||||47.81||33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|47.81||||47.81||33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|47.81||||47.81|22.47|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|47.81||||47.81|0|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|47.81||||47.81|23.91|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|47.81||||47.81|30.12|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|47.81||||47.81|14.18|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|47.81||||47.81||33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|47.81||||47.81|26.3|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|47.81||||47.81|32.99|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|47.81||||47.81|17.69|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|47.81||||47.81||33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|47.81||||47.81|33.94|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|47.81||||47.81|14.18|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|47.81||||47.81||33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|47.81||||47.81|33.94|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|47.81||||47.81|14.18|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|47.81||||47.81|14.18|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|47.81||||47.81|32.99|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|47.81||||47.81|14.18|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|Self-pay|Self-pay|47.81||||47.81|16.73|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|47.81||||47.81|14.18|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|47.81||||47.81|14.18|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|47.81||||47.81|10.48|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|47.81||||47.81||33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|47.81||||47.81||33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|47.81||||47.81|10.48|33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|47.81||||47.81||33.94|10.48
129719|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROCORTISONE SOD SUCCINATE (PF) 100 MG/2 ML SOLUTION FOR INJECTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|47.81||||47.81||33.94|10.48
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AARP [1000]|AARP [100000]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AETNA [1015]|AETNA [101529]|959.76||||959.76|363.84|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|959.76||||959.76|284.57|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS [1155]|BCBS UTHCT [115568]|959.76||||959.76|451.09|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|959.76||||959.76|0|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|959.76||||959.76|479.88|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|959.76||||959.76|604.65|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|959.76||||959.76|284.57|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|CIGNA [1260]|CIGNA GWH [126023]|959.76||||959.76|479.88|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|959.76||||959.76|662.23|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|959.76||||959.76|4.45|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|959.76||||959.76|363.84|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|959.76||||959.76|284.57|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|959.76||||959.76|363.84|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|959.76||||959.76|284.57|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|959.76||||959.76|284.57|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|959.76||||959.76|662.23|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|959.76||||959.76|284.57|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|Self-pay|Self-pay|959.76||||959.76|335.92|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|959.76||||959.76|284.57|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|959.76||||959.76|284.57|662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|959.76||||959.76||662.23|4.45
129766|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 40 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|959.76||||959.76||662.23|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|AARP [1000]|AARP [100000]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|AETNA [1015]|AETNA [101529]|1439.64||||1439.64|545.76|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1439.64||||1439.64|426.85|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|BCBS [1155]|BCBS UTHCT [115568]|1439.64||||1439.64|676.63|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1439.64||||1439.64|0|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1439.64||||1439.64|719.82|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1439.64||||1439.64|906.97|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1439.64||||1439.64|426.85|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|CIGNA [1260]|CIGNA GWH [126023]|1439.64||||1439.64|719.82|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1439.64||||1439.64|993.35|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1439.64||||1439.64|4.45|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1439.64||||1439.64|545.76|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1439.64||||1439.64|426.85|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1439.64||||1439.64|545.76|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1439.64||||1439.64|426.85|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1439.64||||1439.64|426.85|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1439.64||||1439.64|993.35|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1439.64||||1439.64|426.85|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|Self-pay|Self-pay|1439.64||||1439.64|503.87|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1439.64||||1439.64|426.85|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1439.64||||1439.64|426.85|993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1439.64||||1439.64||993.35|4.45
129768|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 60 MCG/0.3 ML IN POLYSORBATE INJECTION SYRINGE|0.3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1439.64||||1439.64||993.35|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|2399.4||||2399.4|909.6|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2399.4||||2399.4|711.42|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|2399.4||||2399.4|1127.72|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2399.4||||2399.4|0|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2399.4||||2399.4|1199.7|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2399.4||||2399.4|1511.62|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2399.4||||2399.4|711.42|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|2399.4||||2399.4|1199.7|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2399.4||||2399.4|1655.59|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2399.4||||2399.4|4.45|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2399.4||||2399.4|909.6|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2399.4||||2399.4|711.42|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2399.4||||2399.4|909.6|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2399.4||||2399.4|711.42|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2399.4||||2399.4|711.42|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2399.4||||2399.4|1655.59|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2399.4||||2399.4|711.42|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|Self-pay|Self-pay|2399.4||||2399.4|839.79|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2399.4||||2399.4|711.42|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2399.4||||2399.4|711.42|1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2399.4||||2399.4||1655.59|4.45
129774|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 100 MCG/0.5 ML IN POLYSORBATE INJECTION SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2399.4||||2399.4||1655.59|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AARP [1000]|AARP [100000]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AETNA [1015]|AETNA [101529]|4798.8||||4798.8|1819.2|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4798.8||||4798.8|1422.84|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS [1155]|BCBS UTHCT [115568]|4798.8||||4798.8|2255.44|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4798.8||||4798.8|0|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4798.8||||4798.8|2399.4|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4798.8||||4798.8|3023.24|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4798.8||||4798.8|1422.84|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|CIGNA [1260]|CIGNA GWH [126023]|4798.8||||4798.8|2399.4|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4798.8||||4798.8|3311.17|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4798.8||||4798.8|4.45|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4798.8||||4798.8|1819.2|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4798.8||||4798.8|1422.84|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4798.8||||4798.8|1819.2|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4798.8||||4798.8|1422.84|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4798.8||||4798.8|1422.84|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4798.8||||4798.8|3311.17|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4798.8||||4798.8|1422.84|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|Self-pay|Self-pay|4798.8||||4798.8|1679.58|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4798.8||||4798.8|1422.84|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4798.8||||4798.8|1422.84|3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4798.8||||4798.8||3311.17|4.45
129780|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 200 MCG/0.4 ML IN POLYSORBATE INJECTION SYRINGE|0.4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4798.8||||4798.8||3311.17|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|AARP [1000]|AARP [100000]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|AETNA [1015]|AETNA [101529]|7198.2||||7198.2|2728.8|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7198.2||||7198.2|2134.27|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|BCBS [1155]|BCBS UTHCT [115568]|7198.2||||7198.2|3383.15|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7198.2||||7198.2|0|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7198.2||||7198.2|3599.1|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7198.2||||7198.2|4534.87|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7198.2||||7198.2|2134.27|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|CIGNA [1260]|CIGNA GWH [126023]|7198.2||||7198.2|3599.1|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7198.2||||7198.2|4966.76|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7198.2||||7198.2|4.45|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7198.2||||7198.2|2728.8|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7198.2||||7198.2|2134.27|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7198.2||||7198.2|2728.8|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7198.2||||7198.2|2134.27|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7198.2||||7198.2|2134.27|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7198.2||||7198.2|4966.76|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7198.2||||7198.2|2134.27|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|Self-pay|Self-pay|7198.2||||7198.2|2519.37|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7198.2||||7198.2|2134.27|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7198.2||||7198.2|2134.27|4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7198.2||||7198.2||4966.76|4.45
129781|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARBEPOETIN ALFA 300 MCG/0.6 ML IN POLYSORBATE INJECTION SYRINGE|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7198.2||||7198.2||4966.76|4.45
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|7.94||||7.94|3.5|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|7.94||||7.94|3.5|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|7.94||||7.94|3.73|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|7.94||||7.94|3.73|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.94||||7.94|3.97|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.94||||7.94|3.97|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.94||||7.94|3.97|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.94||||7.94|3.97|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.94||||7.94|5|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.94||||7.94|5|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|7.94||||7.94|4.37|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|7.94||||7.94|4.37|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.94||||7.94|5.48|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.94||||7.94|5.48|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.94||||7.94|3.97|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.94||||7.94|3.97|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.94||||7.94|3.5|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.94||||7.94|3.5|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.94||||7.94|3.5|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.94||||7.94|3.5|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.94||||7.94|5.48|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.94||||7.94|5.48|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|Self-pay|Self-pay|7.94||||7.94|2.78|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|Self-pay|Self-pay|7.94||||7.94|2.78|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.94||||7.94|2.35|5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.94||||7.94||5.48|2.35
1299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 1,250 MG/5 ML (500 MG/5ML CALCIUM ELEMENTAL) ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.94||||7.94||5.48|2.35
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AARP [1000]|AARP [100000]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AETNA [1015]|AETNA [101529]|96.1||||96.1|42.38|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|96.1||||96.1|28.49|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BCBS UTHCT [115568]|96.1||||96.1|45.17|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|96.1||||96.1|48.05|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|96.1||||96.1|48.05|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|96.1||||96.1|60.54|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|96.1||||96.1|28.49|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA [1260]|CIGNA GWH [126023]|96.1||||96.1|52.86|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|96.1||||96.1|66.31|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|96.1||||96.1|48.05|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|96.1||||96.1|42.38|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|96.1||||96.1|28.49|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|96.1||||96.1|42.38|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|96.1||||96.1|28.49|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|96.1||||96.1|28.49|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|96.1||||96.1|66.31|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|96.1||||96.1|28.49|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|Self-pay|Self-pay|96.1||||96.1|33.63|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|96.1||||96.1|28.49|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|96.1||||96.1|28.49|66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|96.1||||96.1||66.31|28.49
129900|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 40 MG/250 ML (160 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|96.1||||96.1||66.31|28.49
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|30.12||||30.12|13.28|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.12||||30.12|8.93|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|30.12||||30.12|14.16|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.12||||30.12|15.06|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.12||||30.12|15.06|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.12||||30.12|18.98|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.12||||30.12|8.93|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|30.12||||30.12|16.57|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|30.12||||30.12|20.78|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.12||||30.12|15.06|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.12||||30.12|13.28|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.12||||30.12|8.93|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.12||||30.12|13.28|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.12||||30.12|8.93|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.12||||30.12|8.93|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|30.12||||30.12|20.78|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.12||||30.12|8.93|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|Self-pay|Self-pay|30.12||||30.12|10.54|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.12||||30.12|8.93|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.12||||30.12|8.93|20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.12||||30.12||20.78|8.93
129911|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 24 MG-VALSARTAN 26 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|30.12||||30.12|13.28|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.12||||30.12|8.93|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|30.12||||30.12|14.16|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.12||||30.12|15.06|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.12||||30.12|15.06|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.12||||30.12|18.98|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.12||||30.12|8.93|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|30.12||||30.12|16.57|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|30.12||||30.12|20.78|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.12||||30.12|15.06|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.12||||30.12|13.28|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.12||||30.12|8.93|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.12||||30.12|13.28|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.12||||30.12|8.93|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.12||||30.12|8.93|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|30.12||||30.12|20.78|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.12||||30.12|8.93|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|Self-pay|Self-pay|30.12||||30.12|10.54|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.12||||30.12|8.93|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.12||||30.12|8.93|20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.12||||30.12||20.78|8.93
129912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SACUBITRIL 49 MG-VALSARTAN 51 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.12||||30.12||20.78|8.93
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AARP [1000]|AARP [100000]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AETNA [1015]|AETNA [101529]|199.95||||199.95|88.18|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|199.95||||199.95|59.29|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS [1155]|BCBS UTHCT [115568]|199.95||||199.95|93.98|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|199.95||||199.95|99.98|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|199.95||||199.95|99.98|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|199.95||||199.95|125.97|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|199.95||||199.95|59.29|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|CIGNA [1260]|CIGNA GWH [126023]|199.95||||199.95|109.97|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|199.95||||199.95|137.97|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|199.95||||199.95|99.98|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|199.95||||199.95|88.18|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|199.95||||199.95|59.29|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|199.95||||199.95|88.18|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|199.95||||199.95|59.29|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|199.95||||199.95|59.29|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|199.95||||199.95|137.97|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|199.95||||199.95|59.29|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|Self-pay|Self-pay|199.95||||199.95|69.98|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|199.95||||199.95|59.29|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|199.95||||199.95|59.29|137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|199.95||||199.95||137.97|59.29
130102|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN DEXTROSE 5 % IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|199.95||||199.95||137.97|59.29
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|AARP [1000]|AARP [100000]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|AETNA [1015]|AETNA [101529]|283.72||||283.72|125.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|283.72||||283.72|84.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|BCBS [1155]|BCBS UTHCT [115568]|283.72||||283.72|133.35|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|283.72||||283.72|141.86|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|283.72||||283.72|141.86|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|283.72||||283.72|178.74|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|283.72||||283.72|84.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|CIGNA [1260]|CIGNA GWH [126023]|283.72||||283.72|156.05|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|GROUP PENSION ADMIN [1450]|GPA [145000]|283.72||||283.72|195.77|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|283.72||||283.72|141.86|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|283.72||||283.72|125.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|283.72||||283.72|84.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|283.72||||283.72|125.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|283.72||||283.72|84.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|283.72||||283.72|84.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|PHCS [1780]|PHCS MULTIPLAN [178000]|283.72||||283.72|195.77|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|283.72||||283.72|84.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|Self-pay|Self-pay|283.72||||283.72|99.3|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|283.72||||283.72|84.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|283.72||||283.72|84.12|195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|283.72||||283.72||195.77|84.12
13031|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION|176 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|283.72||||283.72||195.77|84.12
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|AARP [1000]|AARP [100000]|4382.11||||4382.11|1393.56|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4382.11||||4382.11|1333.56|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|AETNA [1015]|AETNA [101529]|4382.11||||4382.11|2857.68|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4382.11||||4382.11|1299.3|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4382.11||||4382.11|1320.35|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4382.11||||4382.11|1320.35|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|BCBS [1155]|BCBS UTHCT [115568]|4382.11||||4382.11|2059.59|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4382.11||||4382.11|0|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4382.11||||4382.11|2191.06|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4382.11||||4382.11|2760.73|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4382.11||||4382.11|1299.3|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4382.11||||4382.11|1320.35|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|CIGNA [1260]|CIGNA GWH [126023]|4382.11||||4382.11|2191.06|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|4382.11||||4382.11|3023.66|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4382.11||||4382.11|3.63|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4382.11||||4382.11|1320.35|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4382.11||||4382.11|2857.68|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4382.11||||4382.11|1299.3|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4382.11||||4382.11|1320.35|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4382.11||||4382.11|2857.68|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4382.11||||4382.11|1299.3|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|4382.11||||4382.11|1299.3|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|4382.11||||4382.11|3023.66|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4382.11||||4382.11|1299.3|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|Self-pay|Self-pay|4382.11||||4382.11|1533.74|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4382.11||||4382.11|1299.3|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4382.11||||4382.11|1299.3|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4382.11||||4382.11|1393.56|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4382.11||||4382.11|1320.35|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4382.11||||4382.11|1320.35|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4382.11||||4382.11|1393.56|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4382.11||||4382.11|1320.35|3023.66|3.63
130363|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARIPIPRAZOLE LAUROXIL ER 441 MG/1.6 ML SUSPENSION, EXT.REL. IM SYRINGE|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4382.11||||4382.11|2640.71|3023.66|3.63
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|AARP [1000]|AARP [100000]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|AETNA [1015]|AETNA [101529]|1563.5||||1563.5|0|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1563.5||||1563.5|463.58|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|BCBS [1155]|BCBS UTHCT [115568]|1563.5||||1563.5|734.85|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1563.5||||1563.5|0|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1563.5||||1563.5|781.75|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1563.5||||1563.5|985.01|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1563.5||||1563.5|463.58|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|CIGNA [1260]|CIGNA GWH [126023]|1563.5||||1563.5|859.93|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|1563.5||||1563.5|1078.82|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1563.5||||1563.5|781.75|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1563.5||||1563.5|0|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1563.5||||1563.5|463.58|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1563.5||||1563.5|0|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1563.5||||1563.5|463.58|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|1563.5||||1563.5|463.58|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|1563.5||||1563.5|1078.82|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1563.5||||1563.5|463.58|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|Self-pay|Self-pay|1563.5||||1563.5|547.22|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1563.5||||1563.5|463.58|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1563.5||||1563.5|463.58|1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1563.5||||1563.5||1078.82|463.58
130411|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SULFUR COLLOID PER DOSE UP TO 20MCI|20 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1563.5||||1563.5||1078.82|463.58
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|AARP [1000]|AARP [100000]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|AETNA [1015]|AETNA [101529]|7663.2||||7663.2|5595.5|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7663.2||||7663.2|2272.14|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|BCBS [1155]|BCBS UTHCT [115568]|7663.2||||7663.2|3601.7|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7663.2||||7663.2|0|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7663.2||||7663.2|3831.6|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7663.2||||7663.2|4827.82|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7663.2||||7663.2|2272.14|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|CIGNA [1260]|CIGNA GWH [126023]|7663.2||||7663.2|3831.6|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7663.2||||7663.2|5287.61|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7663.2||||7663.2|67.89|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7663.2||||7663.2|5595.5|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7663.2||||7663.2|2272.14|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7663.2||||7663.2|5595.5|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7663.2||||7663.2|2272.14|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7663.2||||7663.2|2272.14|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7663.2||||7663.2|5287.61|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7663.2||||7663.2|2272.14|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|Self-pay|Self-pay|7663.2||||7663.2|2682.12|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7663.2||||7663.2|2272.14|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7663.2||||7663.2|2272.14|5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7663.2||||7663.2||5595.5|67.89
130463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN LIPOSOMAL 4.3 MG/ML INTRAVENOUS|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7663.2||||7663.2||5595.5|67.89
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|AARP [1000]|AARP [100000]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|AETNA [1015]|AETNA [101529]|32.84||||32.84|14.48|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32.84||||32.84|9.74|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|BCBS [1155]|BCBS UTHCT [115568]|32.84||||32.84|15.43|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32.84||||32.84|16.42|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32.84||||32.84|16.42|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32.84||||32.84|20.69|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32.84||||32.84|9.74|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|CIGNA [1260]|CIGNA GWH [126023]|32.84||||32.84|18.06|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|32.84||||32.84|22.66|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|32.84||||32.84|16.42|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32.84||||32.84|14.48|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32.84||||32.84|9.74|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32.84||||32.84|14.48|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32.84||||32.84|9.74|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|32.84||||32.84|9.74|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|32.84||||32.84|22.66|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32.84||||32.84|9.74|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|Self-pay|Self-pay|32.84||||32.84|11.49|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|32.84||||32.84|9.74|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32.84||||32.84|9.74|22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32.84||||32.84||22.66|9.74
130520|ERX|0250 - PHARMACY-GENERAL|TETRACAINE HCL (PF) 0.5 % EYE DROPS|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32.84||||32.84||22.66|9.74
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AARP [1000]|AARP [100000]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AETNA [1015]|AETNA [101529]|27.9||||27.9|12.3|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.9||||27.9|8.27|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BCBS UTHCT [115568]|27.9||||27.9|13.11|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.9||||27.9|13.95|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.9||||27.9|13.95|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.9||||27.9|17.58|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.9||||27.9|8.27|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|CIGNA [1260]|CIGNA GWH [126023]|27.9||||27.9|15.35|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.9||||27.9|19.25|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.9||||27.9|13.95|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.9||||27.9|12.3|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.9||||27.9|8.27|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.9||||27.9|12.3|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.9||||27.9|8.27|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.9||||27.9|8.27|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.9||||27.9|19.25|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.9||||27.9|8.27|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|Self-pay|Self-pay|27.9||||27.9|9.76|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.9||||27.9|8.27|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.9||||27.9|8.27|19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.9||||27.9||19.25|8.27
1306|ERX|0250 - PHARMACY-GENERAL|CALCIUM CHLORIDE 100 MG/ML (10 %) INTRAVENOUS SYRINGE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.9||||27.9||19.25|8.27
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|0.97||||0.97|0.43|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.97||||0.97|0.29|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.97||||0.97|0.46|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.97||||0.97|0.49|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.97||||0.97|0.49|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.97||||0.97|0.61|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.97||||0.97|0.29|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.97||||0.97|0.53|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.97||||0.97|0.67|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.97||||0.97|0.49|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.97||||0.97|0.43|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.97||||0.97|0.29|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.97||||0.97|0.43|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.97||||0.97|0.29|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.97||||0.97|0.29|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.97||||0.97|0.67|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.97||||0.97|0.29|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|0.97||||0.97|0.34|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.97||||0.97|0.29|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.97||||0.97|0.29|0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.97||||0.97||0.67|0.29
13073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 240 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.97||||0.97||0.67|0.29
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|AARP [1000]|AARP [100000]|5479.1||||5479.1|2739.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5479.1||||5479.1|140.48|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|AETNA [1015]|AETNA [101529]|5479.1||||5479.1|494.14|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5479.1||||5479.1|1624.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5479.1||||5479.1|139.09|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5479.1||||5479.1|139.09|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|BCBS [1155]|BCBS UTHCT [115568]|5479.1||||5479.1|2575.18|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5479.1||||5479.1|0|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5479.1||||5479.1|2739.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5479.1||||5479.1|3451.83|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5479.1||||5479.1|1624.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5479.1||||5479.1|139.09|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|CIGNA [1260]|CIGNA GWH [126023]|5479.1||||5479.1|2739.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|5479.1||||5479.1|3780.58|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5479.1||||5479.1|286.16|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5479.1||||5479.1|139.09|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5479.1||||5479.1|494.14|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5479.1||||5479.1|1624.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5479.1||||5479.1|139.09|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5479.1||||5479.1|494.14|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5479.1||||5479.1|1624.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|5479.1||||5479.1|1624.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|5479.1||||5479.1|3780.58|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5479.1||||5479.1|1624.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|Self-pay|Self-pay|5479.1||||5479.1|1917.68|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5479.1||||5479.1|1624.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5479.1||||5479.1|1624.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5479.1||||5479.1|2739.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5479.1||||5479.1|139.09|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5479.1||||5479.1|139.09|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5479.1||||5479.1|2739.55|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5479.1||||5479.1|139.09|3780.58|139.09
130740|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT|7.5 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5479.1||||5479.1|278.18|3780.58|139.09
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.08||||0.08|0.04|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.08||||0.08|0.02|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.08||||0.08|0.04|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.08||||0.08|0.04|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.08||||0.08|0.04|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.08||||0.08|0.05|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.08||||0.08|0.02|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.08||||0.08|0.04|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.08||||0.08|0.06|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.08||||0.08|0.04|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.08||||0.08|0.04|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.08||||0.08|0.02|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.08||||0.08|0.04|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.08||||0.08|0.02|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.08||||0.08|0.02|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.08||||0.08|0.06|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.08||||0.08|0.02|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.08||||0.08|0.03|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.08||||0.08|0.02|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.08||||0.08|0.02|0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.08||||0.08||0.06|0.02
13089|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.08||||0.08||0.06|0.02
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|AARP [1000]|AARP [100000]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|AETNA [1015]|AETNA [101529]|450||||450|0|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450||||450|133.43|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|BCBS [1155]|BCBS UTHCT [115568]|450||||450|211.5|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450||||450|0|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450||||450|225|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450||||450|283.5|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450||||450|133.43|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|CIGNA [1260]|CIGNA GWH [126023]|450||||450|247.5|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|450||||450|310.5|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|450||||450|225|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450||||450|0|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450||||450|133.43|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450||||450|0|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450||||450|133.43|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|450||||450|133.43|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|450||||450|310.5|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450||||450|133.43|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|Self-pay|Self-pay|450||||450|157.5|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|450||||450|133.43|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450||||450|133.43|310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450||||450||310.5|133.43
130892|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MAA PER DOSE UP TO 10MCI|10 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450||||450||310.5|133.43
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AARP [1000]|AARP [100000]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AETNA [1015]|AETNA [101529]|66.65||||66.65|29.39|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66.65||||66.65|19.76|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BCBS UTHCT [115568]|66.65||||66.65|31.33|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66.65||||66.65|33.33|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66.65||||66.65|33.33|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66.65||||66.65|41.99|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66.65||||66.65|19.76|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA [1260]|CIGNA GWH [126023]|66.65||||66.65|36.66|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66.65||||66.65|45.99|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66.65||||66.65|33.33|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.65||||66.65|29.39|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66.65||||66.65|19.76|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66.65||||66.65|29.39|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66.65||||66.65|19.76|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|66.65||||66.65|19.76|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66.65||||66.65|45.99|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66.65||||66.65|19.76|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|Self-pay|Self-pay|66.65||||66.65|23.33|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66.65||||66.65|19.76|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66.65||||66.65|19.76|45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66.65||||66.65||45.99|19.76
130976|ERX|0250 - PHARMACY-GENERAL|PHENYLEPHRINE 20 MG/250 ML (80 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66.65||||66.65||45.99|19.76
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|AARP [1000]|AARP [100000]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|AETNA [1015]|AETNA [101529]|215.45||||215.45|95.01|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|215.45||||215.45|63.88|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BCBS UTHCT [115568]|215.45||||215.45|101.26|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|215.45||||215.45|107.73|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|215.45||||215.45|107.73|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|215.45||||215.45|135.73|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|215.45||||215.45|63.88|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|CIGNA [1260]|CIGNA GWH [126023]|215.45||||215.45|118.5|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|215.45||||215.45|148.66|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|215.45||||215.45|107.73|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|215.45||||215.45|95.01|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|215.45||||215.45|63.88|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|215.45||||215.45|95.01|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|215.45||||215.45|63.88|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|215.45||||215.45|63.88|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|215.45||||215.45|148.66|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|215.45||||215.45|63.88|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|Self-pay|Self-pay|215.45||||215.45|75.41|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|215.45||||215.45|63.88|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|215.45||||215.45|63.88|148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|215.45||||215.45||148.66|63.88
131038|ERX|0250 - PHARMACY-GENERAL|NOREPINEPHRINE BITARTRATE 16 MG/250 ML (64 MCG/ML) IN 0.9 % NACL IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|215.45||||215.45||148.66|63.88
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|1.45||||1.45|0.64|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.45||||1.45|0.43|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1.45||||1.45|0.68|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.45||||1.45|0.73|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.45||||1.45|0.73|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.45||||1.45|0.91|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.45||||1.45|0.43|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1.45||||1.45|0.8|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.45||||1.45|1|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.45||||1.45|0.73|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.45||||1.45|0.64|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.45||||1.45|0.43|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.45||||1.45|0.64|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.45||||1.45|0.43|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.45||||1.45|0.43|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.45||||1.45|1|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.45||||1.45|0.43|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|1.45||||1.45|0.51|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.45||||1.45|0.43|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.45||||1.45|0.43|1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.45||||1.45||1|0.43
131099|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.45||||1.45||1|0.43
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|15.54||||15.54|10.06|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|15.54||||15.54|10.06|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|15.54||||15.54|7.3|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|15.54||||15.54|7.3|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.54||||15.54|0|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.54||||15.54|0|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.54||||15.54|7.77|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.54||||15.54|7.77|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.54||||15.54|9.79|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.54||||15.54|9.79|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|15.54||||15.54|8.55|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|15.54||||15.54|8.55|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.54||||15.54|10.72|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.54||||15.54|10.72|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.54||||15.54|4.81|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.54||||15.54|4.81|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.54||||15.54|10.06|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.54||||15.54|10.06|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.54||||15.54|10.06|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.54||||15.54|10.06|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.54||||15.54|10.72|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.54||||15.54|10.72|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|15.54||||15.54|5.44|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|15.54||||15.54|5.44|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.54||||15.54|4.61|10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.54||||15.54||10.72|4.61
1312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCIUM GLUCONATE 100 MG/ML (10 %) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.54||||15.54||10.72|4.61
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|34.2||||34.2|15.08|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.2||||34.2|10.14|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|34.2||||34.2|16.07|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.2||||34.2|17.1|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.2||||34.2|17.1|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.2||||34.2|21.55|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.2||||34.2|10.14|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|34.2||||34.2|18.81|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|34.2||||34.2|23.6|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34.2||||34.2|17.1|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.2||||34.2|15.08|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.2||||34.2|10.14|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.2||||34.2|15.08|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.2||||34.2|10.14|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|34.2||||34.2|10.14|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|34.2||||34.2|23.6|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.2||||34.2|10.14|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|34.2||||34.2|11.97|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34.2||||34.2|10.14|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.2||||34.2|10.14|23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.2||||34.2||23.6|10.14
131229|ERX|0250 - PHARMACY-GENERAL|MVI,ADULT NO.4 WITH VIT K 3300 UNIT-150 MCG/10 ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.2||||34.2||23.6|10.14
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|17.98||||17.98|2.3|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.98||||17.98||12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|17.98||||17.98|2.88|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.98||||17.98|5.33|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.98||||17.98||12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.98||||17.98||12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BCBS UTHCT [115568]|17.98||||17.98|8.45|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.98||||17.98|0|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.98||||17.98|8.99|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.98||||17.98|11.33|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.98||||17.98|5.33|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.98||||17.98||12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA GWH [126023]|17.98||||17.98|9.89|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.98||||17.98|12.41|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.98||||17.98|0.18|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.98||||17.98||12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.98||||17.98|2.88|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.98||||17.98|5.33|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.98||||17.98||12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.98||||17.98|2.88|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.98||||17.98|5.33|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.98||||17.98|5.33|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.98||||17.98|12.41|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.98||||17.98|5.33|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|17.98||||17.98|6.29|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.98||||17.98|5.33|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.98||||17.98|5.33|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.98||||17.98|2.3|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.98||||17.98||12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.98||||17.98||12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.98||||17.98|2.3|12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.98||||17.98||12.41|0.18
131313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 10 MG/50 ML IN 0.9 % SOD.CHLORIDE  INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.98||||17.98||12.41|0.18
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AARP [1000]|AARP [100000]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AETNA [1015]|AETNA [101529]|74.4||||74.4|32.81|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.4||||74.4|22.06|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS [1155]|BCBS UTHCT [115568]|74.4||||74.4|34.97|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.4||||74.4|37.2|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.4||||74.4|37.2|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.4||||74.4|46.87|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.4||||74.4|22.06|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|CIGNA [1260]|CIGNA GWH [126023]|74.4||||74.4|40.92|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|74.4||||74.4|51.34|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.4||||74.4|37.2|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.4||||74.4|32.81|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.4||||74.4|22.06|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.4||||74.4|32.81|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.4||||74.4|22.06|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.4||||74.4|22.06|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|74.4||||74.4|51.34|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.4||||74.4|22.06|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|Self-pay|Self-pay|74.4||||74.4|26.04|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.4||||74.4|22.06|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.4||||74.4|22.06|51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.4||||74.4||51.34|22.06
131322|ERX|0250 - PHARMACY-GENERAL|ISOFLURANE 99.9 % INHALATION LIQUID|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.4||||74.4||51.34|22.06
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.92||||9.92|4.37|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.92||||9.92|2.94|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|9.92||||9.92|4.66|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.92||||9.92|4.96|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.92||||9.92|4.96|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.92||||9.92|6.25|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.92||||9.92|2.94|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|9.92||||9.92|5.46|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.92||||9.92|6.84|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.92||||9.92|4.96|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.92||||9.92|4.37|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.92||||9.92|2.94|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.92||||9.92|4.37|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.92||||9.92|2.94|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.92||||9.92|2.94|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.92||||9.92|6.84|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.92||||9.92|2.94|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|Self-pay|Self-pay|9.92||||9.92|3.47|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.92||||9.92|2.94|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.92||||9.92|2.94|6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.92||||9.92||6.84|2.94
13133|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALACYCLOVIR 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.92||||9.92||6.84|2.94
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AARP [1000]|AARP [100000]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AETNA [1015]|AETNA [101529]|68.98||||68.98|30.42|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|68.98||||68.98|20.45|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BCBS UTHCT [115568]|68.98||||68.98|32.42|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|68.98||||68.98|34.49|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|68.98||||68.98|34.49|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|68.98||||68.98|43.46|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|68.98||||68.98|20.45|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA [1260]|CIGNA GWH [126023]|68.98||||68.98|37.94|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|68.98||||68.98|47.6|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|68.98||||68.98|34.49|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|68.98||||68.98|30.42|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|68.98||||68.98|20.45|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|68.98||||68.98|30.42|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|68.98||||68.98|20.45|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|68.98||||68.98|20.45|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|68.98||||68.98|47.6|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|68.98||||68.98|20.45|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|Self-pay|Self-pay|68.98||||68.98|24.14|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|68.98||||68.98|20.45|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|68.98||||68.98|20.45|47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|68.98||||68.98||47.6|20.45
131589|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|68.98||||68.98||47.6|20.45
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AARP [1000]|AARP [100000]|51.15||||51.15|51.15|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.15||||51.15||51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AETNA [1015]|AETNA [101529]|51.15||||51.15|51.15|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.15||||51.15|15.17|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.15||||51.15||51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.15||||51.15||51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BCBS UTHCT [115568]|51.15||||51.15|24.04|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.15||||51.15|0|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.15||||51.15|25.58|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.15||||51.15|32.22|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.15||||51.15|15.17|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.15||||51.15||51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA [1260]|CIGNA GWH [126023]|51.15||||51.15|28.13|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|51.15||||51.15|35.29|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|51.15||||51.15|1.06|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.15||||51.15||51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.15||||51.15|51.15|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.15||||51.15|15.17|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.15||||51.15||51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.15||||51.15|51.15|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.15||||51.15|15.17|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|51.15||||51.15|15.17|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|51.15||||51.15|35.29|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.15||||51.15|15.17|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|Self-pay|Self-pay|51.15||||51.15|17.9|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|51.15||||51.15|15.17|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.15||||51.15|15.17|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.15||||51.15|51.15|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|51.15||||51.15||51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|51.15||||51.15||51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.15||||51.15|51.15|51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.15||||51.15||51.15|1.06
131643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE HCL 4 MG/250 ML (16 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.15||||51.15||51.15|1.06
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|AARP [1000]|AARP [100000]|13220.7||||13220.7|6610.35|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13220.7||||13220.7|4148.51|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|AETNA [1015]|AETNA [101529]|13220.7||||13220.7|9946.56|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13220.7||||13220.7|3919.94|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13220.7||||13220.7|4107.44|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13220.7||||13220.7|4107.44|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|BCBS [1155]|BCBS UTHCT [115568]|13220.7||||13220.7|6213.73|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13220.7||||13220.7|0|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13220.7||||13220.7|6610.35|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13220.7||||13220.7|8329.04|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13220.7||||13220.7|3919.94|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13220.7||||13220.7|4107.44|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|CIGNA [1260]|CIGNA GWH [126023]|13220.7||||13220.7|6610.35|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|13220.7||||13220.7|9122.28|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13220.7||||13220.7|257.08|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13220.7||||13220.7|4107.44|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13220.7||||13220.7|9946.56|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13220.7||||13220.7|3919.94|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13220.7||||13220.7|4107.44|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13220.7||||13220.7|9946.56|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13220.7||||13220.7|3919.94|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|13220.7||||13220.7|3919.94|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|13220.7||||13220.7|9122.28|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13220.7||||13220.7|3919.94|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|Self-pay|Self-pay|13220.7||||13220.7|4627.24|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13220.7||||13220.7|3919.94|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13220.7||||13220.7|3919.94|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13220.7||||13220.7|6610.35|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13220.7||||13220.7|4107.44|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13220.7||||13220.7|4107.44|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13220.7||||13220.7|6610.35|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13220.7||||13220.7|4107.44|9946.56|257.08
131676|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 20 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|20 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13220.7||||13220.7|8214.88|9946.56|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|AARP [1000]|AARP [100000]|19797.04||||19797.04|9898.52|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19797.04||||19797.04|6222.77|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|AETNA [1015]|AETNA [101529]|19797.04||||19797.04|14919.84|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19797.04||||19797.04|5869.82|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19797.04||||19797.04|6161.16|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19797.04||||19797.04|6161.16|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|BCBS [1155]|BCBS UTHCT [115568]|19797.04||||19797.04|9304.61|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19797.04||||19797.04|0|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19797.04||||19797.04|9898.52|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19797.04||||19797.04|12472.14|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19797.04||||19797.04|5869.82|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19797.04||||19797.04|6161.16|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|CIGNA [1260]|CIGNA GWH [126023]|19797.04||||19797.04|9898.52|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|19797.04||||19797.04|13659.96|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19797.04||||19797.04|257.08|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19797.04||||19797.04|6161.16|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19797.04||||19797.04|14919.84|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19797.04||||19797.04|5869.82|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19797.04||||19797.04|6161.16|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19797.04||||19797.04|14919.84|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19797.04||||19797.04|5869.82|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|19797.04||||19797.04|5869.82|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|19797.04||||19797.04|13659.96|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19797.04||||19797.04|5869.82|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|Self-pay|Self-pay|19797.04||||19797.04|6928.96|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19797.04||||19797.04|5869.82|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19797.04||||19797.04|5869.82|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19797.04||||19797.04|9898.52|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19797.04||||19797.04|6161.16|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19797.04||||19797.04|6161.16|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19797.04||||19797.04|9898.52|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19797.04||||19797.04|6161.16|14919.84|257.08
131678|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE,MICROSPHERES ER 30 MG INTRAMUSCULAR SUSP, EXTENDED RELEASE|30 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19797.04||||19797.04|12322.32|14919.84|257.08
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|AARP [1000]|AARP [100000]|0.76||||0.76|0.76|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.76||||0.76||0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|AETNA [1015]|AETNA [101529]|0.76||||0.76|0.53|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.76||||0.76|0.23|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.76||||0.76||0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.76||||0.76||0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|BCBS [1155]|BCBS UTHCT [115568]|0.76||||0.76|0.36|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.76||||0.76|0|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.76||||0.76|0.38|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.76||||0.76|0.48|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.76||||0.76|0.23|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.76||||0.76||0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|CIGNA [1260]|CIGNA GWH [126023]|0.76||||0.76|0.42|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.76||||0.76|0.52|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.76||||0.76|0.15|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.76||||0.76||0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.76||||0.76|0.53|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.76||||0.76|0.23|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.76||||0.76||0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.76||||0.76|0.53|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.76||||0.76|0.23|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.76||||0.76|0.23|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.76||||0.76|0.52|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.76||||0.76|0.23|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|Self-pay|Self-pay|0.76||||0.76|0.27|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.76||||0.76|0.23|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.76||||0.76|0.23|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.76||||0.76|0.76|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.76||||0.76||0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.76||||0.76||0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.76||||0.76|0.76|0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.76||||0.76||0.76|0.15
131800|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM (PF) 5 MG/ML INJECTION SOLUTION|0.4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.76||||0.76||0.76|0.15
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.87||||1.87|0.82|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.87||||1.87|0.55|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.87||||1.87|0.88|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.87||||1.87|0.94|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.87||||1.87|0.94|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.87||||1.87|1.18|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.87||||1.87|0.55|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.87||||1.87|1.03|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.87||||1.87|1.29|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.87||||1.87|0.94|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.87||||1.87|0.82|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.87||||1.87|0.55|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.87||||1.87|0.82|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.87||||1.87|0.55|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.87||||1.87|0.55|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.87||||1.87|1.29|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.87||||1.87|0.55|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|1.87||||1.87|0.65|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.87||||1.87|0.55|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.87||||1.87|0.55|1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.87||||1.87||1.29|0.55
13184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 120 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.87||||1.87||1.29|0.55
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|3.83||||3.83|1.69|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.83||||3.83|1.14|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|3.83||||3.83|1.8|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.83||||3.83|1.92|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.83||||3.83|1.92|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.83||||3.83|2.41|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.83||||3.83|1.14|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|3.83||||3.83|2.11|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.83||||3.83|2.64|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.83||||3.83|1.92|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.83||||3.83|1.69|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.83||||3.83|1.14|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.83||||3.83|1.69|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.83||||3.83|1.14|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.83||||3.83|1.14|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.83||||3.83|2.64|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.83||||3.83|1.14|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|3.83||||3.83|1.34|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.83||||3.83|1.14|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.83||||3.83|1.14|2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.83||||3.83||2.64|1.14
131854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML (5 ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.83||||3.83||2.64|1.14
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|AARP [1000]|AARP [100000]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|AETNA [1015]|AETNA [101529]|4.54||||4.54|2|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.54||||4.54|1.35|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|BCBS [1155]|BCBS UTHCT [115568]|4.54||||4.54|2.13|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.54||||4.54|2.27|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.54||||4.54|2.27|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.54||||4.54|2.86|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.54||||4.54|1.35|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|CIGNA [1260]|CIGNA GWH [126023]|4.54||||4.54|2.5|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.54||||4.54|3.13|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.54||||4.54|2.27|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.54||||4.54|2|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.54||||4.54|1.35|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.54||||4.54|2|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.54||||4.54|1.35|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.54||||4.54|1.35|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.54||||4.54|3.13|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.54||||4.54|1.35|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|Self-pay|Self-pay|4.54||||4.54|1.59|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.54||||4.54|1.35|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.54||||4.54|1.35|3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.54||||4.54||3.13|1.35
131866|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG/12.5 ML (12.5 ML) ORAL SOLUTION|12.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.54||||4.54||3.13|1.35
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|8.42||||8.42|6.67|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.42||||8.42||7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|8.42||||8.42|7.46|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.42||||8.42|2.5|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.42||||8.42||7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.42||||8.42||7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|8.42||||8.42|3.96|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.42||||8.42|0|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.42||||8.42|4.21|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.42||||8.42|5.3|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.42||||8.42|2.5|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.42||||8.42||7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|8.42||||8.42|4.63|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.42||||8.42|5.81|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.42||||8.42|3.43|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.42||||8.42||7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.42||||8.42|7.46|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.42||||8.42|2.5|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.42||||8.42||7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.42||||8.42|7.46|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.42||||8.42|2.5|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.42||||8.42|2.5|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.42||||8.42|5.81|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.42||||8.42|2.5|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|Self-pay|Self-pay|8.42||||8.42|2.95|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.42||||8.42|2.5|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.42||||8.42|2.5|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.42||||8.42|6.67|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.42||||8.42||7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.42||||8.42||7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.42||||8.42|6.67|7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.42||||8.42||7.46|2.5
132250|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.42||||8.42||7.46|2.5
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|AARP [1000]|AARP [100000]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|AETNA [1015]|AETNA [101529]|768.5||||768.5|0|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|768.5||||768.5|227.86|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|BCBS [1155]|BCBS UTHCT [115568]|768.5||||768.5|361.2|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|768.5||||768.5|0|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|768.5||||768.5|384.25|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|768.5||||768.5|484.16|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|768.5||||768.5|227.86|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|CIGNA [1260]|CIGNA GWH [126023]|768.5||||768.5|422.68|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|768.5||||768.5|530.27|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|768.5||||768.5|384.25|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|768.5||||768.5|0|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|768.5||||768.5|227.86|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|768.5||||768.5|0|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|768.5||||768.5|227.86|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|768.5||||768.5|227.86|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|768.5||||768.5|530.27|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|768.5||||768.5|227.86|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|Self-pay|Self-pay|768.5||||768.5|268.97|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|768.5||||768.5|227.86|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|768.5||||768.5|227.86|530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|768.5||||768.5||530.27|227.86
132483|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM PET ISO F18 FDG (FLUORDEOXYGLUCOSE) PER DOSE UP TO 45 MCI|45 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|768.5||||768.5||530.27|227.86
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.7||||1.7|0.75|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.7||||1.7|0.5|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.7||||1.7|0.8|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.7||||1.7|0.85|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.7||||1.7|0.85|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.7||||1.7|1.07|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.7||||1.7|0.5|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.7||||1.7|0.94|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.7||||1.7|1.17|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.7||||1.7|0.85|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.7||||1.7|0.75|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.7||||1.7|0.5|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.7||||1.7|0.75|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.7||||1.7|0.5|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.7||||1.7|0.5|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.7||||1.7|1.17|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.7||||1.7|0.5|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|Self-pay|Self-pay|1.7||||1.7|0.59|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.7||||1.7|0.5|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.7||||1.7|0.5|1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.7||||1.7||1.17|0.5
132589|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.61-VIT D3 1,500 UNIT-VIT K 800 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.7||||1.7||1.17|0.5
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AARP [1000]|AARP [100000]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AETNA [1015]|AETNA [101529]|390||||390|0|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|390||||390|115.64|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|BCBS [1155]|BCBS UTHCT [115568]|390||||390|183.3|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|390||||390|0|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|390||||390|195|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|390||||390|245.7|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|390||||390|115.64|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|CIGNA [1260]|CIGNA GWH [126023]|390||||390|214.5|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|390||||390|269.1|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|390||||390|195|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|390||||390|0|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|390||||390|115.64|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|390||||390|0|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|390||||390|115.64|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|390||||390|115.64|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|390||||390|269.1|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|390||||390|115.64|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|Self-pay|Self-pay|390||||390|136.5|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|390||||390|115.64|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|390||||390|115.64|269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|390||||390||269.1|115.64
133293|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M TETROFOSMIN (MYOVIEW) PER DOSE|1 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|390||||390||269.1|115.64
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|340.82||||340.82|150.3|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|340.82||||340.82|101.05|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|340.82||||340.82|160.19|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|340.82||||340.82|170.41|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|340.82||||340.82|170.41|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|340.82||||340.82|214.72|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|340.82||||340.82|101.05|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|340.82||||340.82|187.45|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|340.82||||340.82|235.17|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|340.82||||340.82|170.41|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|340.82||||340.82|150.3|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|340.82||||340.82|101.05|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|340.82||||340.82|150.3|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|340.82||||340.82|101.05|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|340.82||||340.82|101.05|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|340.82||||340.82|235.17|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|340.82||||340.82|101.05|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|340.82||||340.82|119.29|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|340.82||||340.82|101.05|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|340.82||||340.82|101.05|235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|340.82||||340.82||235.17|101.05
133312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUGAMMADEX 100 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|340.82||||340.82||235.17|101.05
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
133509|ERX|0250 - PHARMACY-GENERAL|DILUENT FOR HAEMOPHILUS B VACCINE (TETANUS CONJUGATE) (0.4 % NACL)|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|AARP [1000]|AARP [100000]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|AETNA [1015]|AETNA [101529]|17.64||||17.64|7.78|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.64||||17.64|5.23|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|BCBS [1155]|BCBS UTHCT [115568]|17.64||||17.64|8.29|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.64||||17.64|8.82|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.64||||17.64|8.82|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.64||||17.64|11.11|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.64||||17.64|5.23|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|CIGNA [1260]|CIGNA GWH [126023]|17.64||||17.64|9.7|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.64||||17.64|12.17|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.64||||17.64|8.82|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.64||||17.64|7.78|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.64||||17.64|5.23|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.64||||17.64|7.78|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.64||||17.64|5.23|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.64||||17.64|5.23|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.64||||17.64|12.17|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.64||||17.64|5.23|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|Self-pay|Self-pay|17.64||||17.64|6.17|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.64||||17.64|5.23|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.64||||17.64|5.23|12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.64||||17.64||12.17|5.23
133780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.118 ORAL LIQUID|237 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.64||||17.64||12.17|5.23
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AARP [1000]|AARP [100000]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AETNA [1015]|AETNA [101529]|60.58||||60.58|26.72|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60.58||||60.58|17.96|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|60.58||||60.58|28.47|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60.58||||60.58|30.29|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60.58||||60.58|30.29|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60.58||||60.58|38.17|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60.58||||60.58|17.96|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|60.58||||60.58|33.32|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|60.58||||60.58|41.8|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|60.58||||60.58|30.29|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60.58||||60.58|26.72|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60.58||||60.58|17.96|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60.58||||60.58|26.72|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60.58||||60.58|17.96|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|60.58||||60.58|17.96|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|60.58||||60.58|41.8|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60.58||||60.58|17.96|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|Self-pay|Self-pay|60.58||||60.58|21.2|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|60.58||||60.58|17.96|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60.58||||60.58|17.96|41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60.58||||60.58||41.8|17.96
133828|ERX|0250 - PHARMACY-GENERAL|MIDAZOLAM (PF) 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60.58||||60.58||41.8|17.96
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|9817.67||||9817.67|4908.84|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9817.67||||9817.67|2857.29|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|9817.67||||9817.67|6972|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9817.67||||9817.67|2910.94|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9817.67||||9817.67|2829|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9817.67||||9817.67|2829|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|9817.67||||9817.67|4614.3|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9817.67||||9817.67|0|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9817.67||||9817.67|4908.84|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9817.67||||9817.67|6185.13|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9817.67||||9817.67|2910.94|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9817.67||||9817.67|2829|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|9817.67||||9817.67|4908.84|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9817.67||||9817.67|6774.19|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9817.67||||9817.67|36.08|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9817.67||||9817.67|2829|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9817.67||||9817.67|6972|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9817.67||||9817.67|2910.94|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9817.67||||9817.67|2829|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9817.67||||9817.67|6972|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9817.67||||9817.67|2910.94|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9817.67||||9817.67|2910.94|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9817.67||||9817.67|6774.19|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9817.67||||9817.67|2910.94|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|Self-pay|Self-pay|9817.67||||9817.67|3436.18|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9817.67||||9817.67|2910.94|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9817.67||||9817.67|2910.94|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9817.67||||9817.67|4908.84|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9817.67||||9817.67|2829|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9817.67||||9817.67|2829|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9817.67||||9817.67|4908.84|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9817.67||||9817.67|2829|6972|36.08
133919|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPOLIZUMAB 100 MG SUBCUTANEOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9817.67||||9817.67|5658|6972|36.08
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|AARP [1000]|AARP [100000]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|AETNA [1015]|AETNA [101529]|54.26||||54.26|23.93|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54.26||||54.26|16.09|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|BCBS [1155]|BCBS UTHCT [115568]|54.26||||54.26|25.5|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54.26||||54.26|27.13|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54.26||||54.26|27.13|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54.26||||54.26|34.18|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54.26||||54.26|16.09|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|CIGNA [1260]|CIGNA GWH [126023]|54.26||||54.26|29.84|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|54.26||||54.26|37.44|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54.26||||54.26|27.13|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54.26||||54.26|23.93|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54.26||||54.26|16.09|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54.26||||54.26|23.93|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54.26||||54.26|16.09|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|54.26||||54.26|16.09|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|54.26||||54.26|37.44|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54.26||||54.26|16.09|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|Self-pay|Self-pay|54.26||||54.26|18.99|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54.26||||54.26|16.09|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54.26||||54.26|16.09|37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54.26||||54.26||37.44|16.09
133935|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COMPOUNDING VEHICLE SUSPENSION (ORA-PLUS SF) SUGAR-FREE NO.20 ORAL|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54.26||||54.26||37.44|16.09
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|7221.14||||7221.14|3610.57|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7221.14||||7221.14|2325.1|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|7221.14||||7221.14|5381.76|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7221.14||||7221.14|2141.07|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7221.14||||7221.14|2302.08|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7221.14||||7221.14|2302.08|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|7221.14||||7221.14|3393.94|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7221.14||||7221.14|0|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7221.14||||7221.14|3610.57|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7221.14||||7221.14|4549.32|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7221.14||||7221.14|2141.07|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7221.14||||7221.14|2302.08|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|7221.14||||7221.14|3610.57|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7221.14||||7221.14|4982.59|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7221.14||||7221.14|70.05|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7221.14||||7221.14|2302.08|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7221.14||||7221.14|5381.76|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7221.14||||7221.14|2141.07|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7221.14||||7221.14|2302.08|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7221.14||||7221.14|5381.76|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7221.14||||7221.14|2141.07|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7221.14||||7221.14|2141.07|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7221.14||||7221.14|4982.59|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7221.14||||7221.14|2141.07|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|7221.14||||7221.14|2527.4|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7221.14||||7221.14|2141.07|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7221.14||||7221.14|2141.07|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7221.14||||7221.14|3610.57|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7221.14||||7221.14|2302.08|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7221.14||||7221.14|2302.08|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7221.14||||7221.14|3610.57|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7221.14||||7221.14|2302.08|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7221.14||||7221.14|4604.16|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|1805.29||||1805.29|572.1|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1805.29||||1805.29|581.28|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|1805.29||||1805.29|1345.44|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1805.29||||1805.29|535.27|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1805.29||||1805.29|575.52|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1805.29||||1805.29|575.52|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1805.29||||1805.29|848.49|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1805.29||||1805.29|0|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1805.29||||1805.29|902.65|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1805.29||||1805.29|1137.33|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1805.29||||1805.29|535.27|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1805.29||||1805.29|575.52|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1805.29||||1805.29|902.65|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1805.29||||1805.29|1245.65|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1805.29||||1805.29|70.05|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1805.29||||1805.29|575.52|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1805.29||||1805.29|1345.44|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1805.29||||1805.29|535.27|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1805.29||||1805.29|575.52|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1805.29||||1805.29|1345.44|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1805.29||||1805.29|535.27|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1805.29||||1805.29|535.27|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1805.29||||1805.29|1245.65|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1805.29||||1805.29|535.27|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|1805.29||||1805.29|631.85|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1805.29||||1805.29|535.27|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1805.29||||1805.29|535.27|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1805.29||||1805.29|572.1|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1805.29||||1805.29|575.52|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1805.29||||1805.29|575.52|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1805.29||||1805.29|572.1|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1805.29||||1805.29|575.52|5381.76|70.05
133971|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 20 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1805.29||||1805.29|1151.04|5381.76|70.05
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|AARP [1000]|AARP [100000]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|AETNA [1015]|AETNA [101529]|30.88||||30.88|13.62|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.88||||30.88|9.16|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|BCBS [1155]|BCBS UTHCT [115568]|30.88||||30.88|14.51|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.88||||30.88|15.44|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.88||||30.88|15.44|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.88||||30.88|19.45|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.88||||30.88|9.16|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|CIGNA [1260]|CIGNA GWH [126023]|30.88||||30.88|16.98|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|30.88||||30.88|21.31|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.88||||30.88|15.44|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.88||||30.88|13.62|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.88||||30.88|9.16|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.88||||30.88|13.62|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.88||||30.88|9.16|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.88||||30.88|9.16|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|30.88||||30.88|21.31|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.88||||30.88|9.16|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|Self-pay|Self-pay|30.88||||30.88|10.81|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.88||||30.88|9.16|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.88||||30.88|9.16|21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.88||||30.88||21.31|9.16
134035|ERX|0250 - PHARMACY-GENERAL|SELENIUM SULFIDE 2.5 % LOTION|120 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.88||||30.88||21.31|9.16
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AARP [1000]|AARP [100000]|8269.35||||8269.35|4134.68|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8269.35||||8269.35|2735.48|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AETNA [1015]|AETNA [101529]|8269.35||||8269.35|6403.2|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8269.35||||8269.35|2451.86|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8269.35||||8269.35|2708.4|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8269.35||||8269.35|2708.4|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BCBS UTHCT [115568]|8269.35||||8269.35|3886.59|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8269.35||||8269.35|0|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8269.35||||8269.35|4134.68|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8269.35||||8269.35|5209.69|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8269.35||||8269.35|2451.86|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8269.35||||8269.35|2708.4|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|CIGNA [1260]|CIGNA GWH [126023]|8269.35||||8269.35|4134.68|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|8269.35||||8269.35|5705.85|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8269.35||||8269.35|8.34|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8269.35||||8269.35|2708.4|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8269.35||||8269.35|6403.2|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8269.35||||8269.35|2451.86|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8269.35||||8269.35|2708.4|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8269.35||||8269.35|6403.2|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8269.35||||8269.35|2451.86|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|8269.35||||8269.35|2451.86|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|8269.35||||8269.35|5705.85|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8269.35||||8269.35|2451.86|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|Self-pay|Self-pay|8269.35||||8269.35|2894.27|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8269.35||||8269.35|2451.86|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8269.35||||8269.35|2451.86|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8269.35||||8269.35|4134.68|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8269.35||||8269.35|2708.4|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8269.35||||8269.35|2708.4|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8269.35||||8269.35|4134.68|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8269.35||||8269.35|2708.4|6403.2|8.34
134040|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ELOTUZUMAB 400 MG INTRAVENOUS SOLUTION|400 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8269.35||||8269.35|5416.8|6403.2|8.34
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|AARP [1000]|AARP [100000]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|AETNA [1015]|AETNA [101529]|69.75||||69.75|30.76|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69.75||||69.75|20.68|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|BCBS [1155]|BCBS UTHCT [115568]|69.75||||69.75|32.78|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69.75||||69.75|34.88|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69.75||||69.75|34.88|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69.75||||69.75|43.94|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69.75||||69.75|20.68|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|CIGNA [1260]|CIGNA GWH [126023]|69.75||||69.75|38.36|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|69.75||||69.75|48.13|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|69.75||||69.75|34.88|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.75||||69.75|30.76|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69.75||||69.75|20.68|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69.75||||69.75|30.76|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69.75||||69.75|20.68|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|69.75||||69.75|20.68|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|69.75||||69.75|48.13|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69.75||||69.75|20.68|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|Self-pay|Self-pay|69.75||||69.75|24.41|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|69.75||||69.75|20.68|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69.75||||69.75|20.68|48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69.75||||69.75||48.13|20.68
134070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEDIATRIC MULTIVITAMIN NO.128-VITAMIN K 500 MCG/ML ORAL LIQUID|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69.75||||69.75||48.13|20.68
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|7668.78||||7668.78|3834.39|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7668.78||||7668.78|1984.25|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|7668.78||||7668.78|4905.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7668.78||||7668.78|2273.79|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7668.78||||7668.78|1964.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7668.78||||7668.78|1964.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|7668.78||||7668.78|3604.33|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7668.78||||7668.78|0|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7668.78||||7668.78|3834.39|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7668.78||||7668.78|4831.33|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7668.78||||7668.78|2273.79|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7668.78||||7668.78|1964.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|7668.78||||7668.78|3834.39|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7668.78||||7668.78|5291.46|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7668.78||||7668.78|25.21|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7668.78||||7668.78|1964.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7668.78||||7668.78|4905.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7668.78||||7668.78|2273.79|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7668.78||||7668.78|1964.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7668.78||||7668.78|4905.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7668.78||||7668.78|2273.79|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7668.78||||7668.78|2273.79|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7668.78||||7668.78|5291.46|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7668.78||||7668.78|2273.79|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|7668.78||||7668.78|2684.07|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7668.78||||7668.78|2273.79|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7668.78||||7668.78|2273.79|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7668.78||||7668.78|3834.39|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7668.78||||7668.78|1964.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7668.78||||7668.78|1964.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7668.78||||7668.78|3834.39|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7668.78||||7668.78|1964.6|5291.46|25.21
134077|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7668.78||||7668.78|3929.2|5291.46|25.21
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AARP [1000]|AARP [100000]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AETNA [1015]|AETNA [101529]|21.58||||21.58|9.52|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.58||||21.58|6.4|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BCBS UTHCT [115568]|21.58||||21.58|10.14|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.58||||21.58|10.79|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.58||||21.58|10.79|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.58||||21.58|13.6|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.58||||21.58|6.4|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|CIGNA [1260]|CIGNA GWH [126023]|21.58||||21.58|11.87|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|GROUP PENSION ADMIN [1450]|GPA [145000]|21.58||||21.58|14.89|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.58||||21.58|10.79|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.58||||21.58|9.52|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.58||||21.58|6.4|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.58||||21.58|9.52|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.58||||21.58|6.4|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.58||||21.58|6.4|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|PHCS [1780]|PHCS MULTIPLAN [178000]|21.58||||21.58|14.89|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.58||||21.58|6.4|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|Self-pay|Self-pay|21.58||||21.58|7.55|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.58||||21.58|6.4|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.58||||21.58|6.4|14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.58||||21.58||14.89|6.4
1350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPSAICIN 0.025 % TOPICAL CREAM|60 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.58||||21.58||14.89|6.4
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.25||||1.25|0.55|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.25||||1.25|0.37|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.25||||1.25|0.59|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.25||||1.25|0.63|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.25||||1.25|0.63|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.25||||1.25|0.79|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.25||||1.25|0.37|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.25||||1.25|0.69|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.25||||1.25|0.86|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.25||||1.25|0.63|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.25||||1.25|0.55|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.25||||1.25|0.37|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.25||||1.25|0.55|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.25||||1.25|0.37|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.25||||1.25|0.37|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.25||||1.25|0.86|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.25||||1.25|0.37|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|1.25||||1.25|0.44|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.25||||1.25|0.37|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.25||||1.25|0.37|0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.25||||1.25||0.86|0.37
1355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 100 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.25||||1.25||0.86|0.37
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.81||||2.81|1.24|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.81||||2.81|0.83|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.81||||2.81|1.32|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.81||||2.81|1.41|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.81||||2.81|1.41|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.81||||2.81|1.77|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.81||||2.81|0.83|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.81||||2.81|1.55|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.81||||2.81|1.94|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.81||||2.81|1.41|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.81||||2.81|1.24|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.81||||2.81|0.83|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.81||||2.81|1.24|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.81||||2.81|0.83|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.81||||2.81|0.83|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.81||||2.81|1.94|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.81||||2.81|0.83|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|Self-pay|Self-pay|2.81||||2.81|0.98|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.81||||2.81|0.83|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.81||||2.81|0.83|1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.81||||2.81||1.94|0.83
1357|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.81||||2.81||1.94|0.83
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.25||||6.25|2.76|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.25||||6.25|1.85|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|6.25||||6.25|2.94|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.25||||6.25|3.13|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.25||||6.25|3.13|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.25||||6.25|3.94|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.25||||6.25|1.85|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|6.25||||6.25|3.44|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.25||||6.25|4.31|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.25||||6.25|3.13|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.25||||6.25|2.76|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.25||||6.25|1.85|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.25||||6.25|2.76|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.25||||6.25|1.85|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.25||||6.25|1.85|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.25||||6.25|4.31|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.25||||6.25|1.85|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|Self-pay|Self-pay|6.25||||6.25|2.19|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.25||||6.25|1.85|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.25||||6.25|1.85|4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.25||||6.25||4.31|1.85
13577|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.25||||6.25||4.31|1.85
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AARP [1000]|AARP [100000]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AETNA [1015]|AETNA [101529]|13.91||||13.91|6.13|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.91||||13.91|4.12|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|13.91||||13.91|6.54|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.91||||13.91|6.96|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.91||||13.91|6.96|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.91||||13.91|8.76|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.91||||13.91|4.12|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|13.91||||13.91|7.65|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.91||||13.91|9.6|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.91||||13.91|6.96|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.91||||13.91|6.13|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.91||||13.91|4.12|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.91||||13.91|6.13|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.91||||13.91|4.12|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.91||||13.91|4.12|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.91||||13.91|9.6|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.91||||13.91|4.12|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|Self-pay|Self-pay|13.91||||13.91|4.87|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.91||||13.91|4.12|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.91||||13.91|4.12|9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.91||||13.91||9.6|4.12
1359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMIDE PEROXIDE 6.5 % EAR DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.91||||13.91||9.6|4.12
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|AARP [1000]|AARP [100000]|4597.89||||4597.89|1399.96|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4597.89||||4597.89|1420.43|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|AETNA [1015]|AETNA [101529]|4597.89||||4597.89|2986.42|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4597.89||||4597.89|1363.27|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4597.89||||4597.89|1406.37|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4597.89||||4597.89|1406.37|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|BCBS [1155]|BCBS UTHCT [115568]|4597.89||||4597.89|2161.01|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4597.89||||4597.89|0|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4597.89||||4597.89|2298.95|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4597.89||||4597.89|2896.67|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4597.89||||4597.89|1363.27|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4597.89||||4597.89|1406.37|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|CIGNA [1260]|CIGNA GWH [126023]|4597.89||||4597.89|2298.95|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|4597.89||||4597.89|3172.54|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4597.89||||4597.89|1977.66|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4597.89||||4597.89|1406.37|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4597.89||||4597.89|2986.42|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4597.89||||4597.89|1363.27|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4597.89||||4597.89|1406.37|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4597.89||||4597.89|2986.42|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4597.89||||4597.89|1363.27|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|4597.89||||4597.89|1363.27|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|4597.89||||4597.89|3172.54|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4597.89||||4597.89|1363.27|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|Self-pay|Self-pay|4597.89||||4597.89|1609.26|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4597.89||||4597.89|1363.27|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4597.89||||4597.89|1363.27|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4597.89||||4597.89|1399.96|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4597.89||||4597.89|1406.37|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4597.89||||4597.89|1406.37|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4597.89||||4597.89|1399.96|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4597.89||||4597.89|1406.37|3172.54|1363.27
13691|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT|3.75 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4597.89||||4597.89|2812.73|3172.54|1363.27
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AARP [1000]|AARP [100000]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.27||||3.27|1.44|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.27||||3.27|0.97|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.27||||3.27|1.54|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.27||||3.27|1.64|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.27||||3.27|1.64|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.27||||3.27|2.06|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.27||||3.27|0.97|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.27||||3.27|1.8|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.27||||3.27|2.26|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.27||||3.27|1.64|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.27||||3.27|1.44|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.27||||3.27|0.97|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.27||||3.27|1.44|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.27||||3.27|0.97|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.27||||3.27|0.97|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.27||||3.27|2.26|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.27||||3.27|0.97|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|Self-pay|Self-pay|3.27||||3.27|1.14|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.27||||3.27|0.97|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.27||||3.27|0.97|2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.27||||3.27||2.26|0.97
13884|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLESTIPOL 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.27||||3.27||2.26|0.97
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.31||||0.31|0.14|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.31||||0.31|0.09|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.31||||0.31|0.15|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.31||||0.31|0.16|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.31||||0.31|0.16|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.31||||0.31|0.2|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.31||||0.31|0.09|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.31||||0.31|0.17|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.31||||0.31|0.21|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.31||||0.31|0.16|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.31||||0.31|0.14|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.31||||0.31|0.09|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.31||||0.31|0.14|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.31||||0.31|0.09|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.31||||0.31|0.09|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.31||||0.31|0.21|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.31||||0.31|0.09|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|Self-pay|Self-pay|0.31||||0.31|0.11|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.31||||0.31|0.09|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.31||||0.31|0.09|0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.31||||0.31||0.21|0.09
1395|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARISOPRODOL 350 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.31||||0.31||0.21|0.09
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.19||||0.19|0.08|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.19||||0.19|0.06|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.19||||0.19|0.09|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.19||||0.19|0.1|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.19||||0.19|0.1|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.19||||0.19|0.12|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.19||||0.19|0.06|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.19||||0.19|0.1|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.19||||0.19|0.13|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.19||||0.19|0.1|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.19||||0.19|0.08|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.19||||0.19|0.06|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.19||||0.19|0.08|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.19||||0.19|0.06|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.19||||0.19|0.06|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.19||||0.19|0.13|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.19||||0.19|0.06|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.19||||0.19|0.07|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.19||||0.19|0.06|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.19||||0.19|0.06|0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.19||||0.19||0.13|0.06
13981|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.19||||0.19||0.13|0.06
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.6||||0.6|0.26|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.6||||0.6|0.18|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.6||||0.6|0.28|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.6||||0.6|0.3|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.6||||0.6|0.3|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.6||||0.6|0.38|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.6||||0.6|0.18|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.6||||0.6|0.33|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.6||||0.6|0.41|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.6||||0.6|0.3|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.6||||0.6|0.26|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.6||||0.6|0.18|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.6||||0.6|0.26|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.6||||0.6|0.18|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.6||||0.6|0.18|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.6||||0.6|0.41|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.6||||0.6|0.18|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|0.6||||0.6|0.21|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.6||||0.6|0.18|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.6||||0.6|0.18|0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.6||||0.6||0.41|0.18
13982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.6||||0.6||0.41|0.18
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.42||||0.42|0.19|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.42||||0.42|0.12|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.42||||0.42|0.2|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.42||||0.42|0.21|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.42||||0.42|0.21|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.42||||0.42|0.26|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.42||||0.42|0.12|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.42||||0.42|0.23|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.42||||0.42|0.29|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.42||||0.42|0.21|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.42||||0.42|0.19|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.42||||0.42|0.12|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.42||||0.42|0.19|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.42||||0.42|0.12|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.42||||0.42|0.12|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.42||||0.42|0.29|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.42||||0.42|0.12|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|Self-pay|Self-pay|0.42||||0.42|0.15|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.42||||0.42|0.12|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.42||||0.42|0.12|0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.42||||0.42||0.29|0.12
14087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 300 MG-CODEINE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.42||||0.42||0.29|0.12
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|77.5||||77.5|8.09|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|77.5||||77.5|22.98|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|77.5||||77.5|36.43|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|77.5||||77.5|0|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|77.5||||77.5|38.75|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|77.5||||77.5|48.83|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|77.5||||77.5|22.98|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|77.5||||77.5|42.63|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|77.5||||77.5|53.48|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|77.5||||77.5|11.93|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|77.5||||77.5|8.09|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|77.5||||77.5|22.98|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|77.5||||77.5|8.09|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|77.5||||77.5|22.98|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|77.5||||77.5|22.98|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|77.5||||77.5|53.48|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|77.5||||77.5|22.98|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|Self-pay|Self-pay|77.5||||77.5|27.12|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|77.5||||77.5|22.98|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|77.5||||77.5|22.98|53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|77.5||||77.5||53.48|8.09
14203|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINORELBINE 10 MG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|77.5||||77.5||53.48|8.09
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AARP [1000]|AARP [100000]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AETNA [1015]|AETNA [101529]|182.39||||182.39|80.43|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182.39||||182.39|54.08|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|BCBS [1155]|BCBS UTHCT [115568]|182.39||||182.39|85.72|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182.39||||182.39|91.2|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182.39||||182.39|91.2|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182.39||||182.39|114.91|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182.39||||182.39|54.08|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|CIGNA [1260]|CIGNA GWH [126023]|182.39||||182.39|100.31|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|182.39||||182.39|125.85|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|182.39||||182.39|91.2|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182.39||||182.39|80.43|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182.39||||182.39|54.08|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182.39||||182.39|80.43|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182.39||||182.39|54.08|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|182.39||||182.39|54.08|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|182.39||||182.39|125.85|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182.39||||182.39|54.08|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|Self-pay|Self-pay|182.39||||182.39|63.84|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|182.39||||182.39|54.08|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182.39||||182.39|54.08|125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182.39||||182.39||125.85|54.08
14233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUCONAZOLE 40 MG/ML ORAL SUSPENSION|35 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182.39||||182.39||125.85|54.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.28||||0.28|0.12|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.28||||0.28|0.08|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.28||||0.28|0.13|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.28||||0.28|0.14|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.28||||0.28|0.14|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.28||||0.28|0.18|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.28||||0.28|0.08|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.28||||0.28|0.15|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.28||||0.28|0.19|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.28||||0.28|0.14|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.28||||0.28|0.12|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.28||||0.28|0.08|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.28||||0.28|0.12|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.28||||0.28|0.08|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.28||||0.28|0.08|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.28||||0.28|0.19|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.28||||0.28|0.08|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|Self-pay|Self-pay|0.28||||0.28|0.1|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.28||||0.28|0.08|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.28||||0.28|0.08|0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.28||||0.28||0.19|0.08
14266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMOTRIGINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.28||||0.28||0.19|0.08
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AARP [1000]|AARP [100000]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|4.25||||4.25|3.7|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.25||||4.25|1.26|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BCBS UTHCT [115568]|4.25||||4.25|2|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.25||||4.25|0|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.25||||4.25|2.13|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.25||||4.25|2.68|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.25||||4.25|1.26|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA GWH [126023]|4.25||||4.25|2.34|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|4.25||||4.25|2.93|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.25||||4.25|1.03|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.25||||4.25|3.7|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.25||||4.25|1.26|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.25||||4.25|3.7|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.25||||4.25|1.26|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.25||||4.25|1.26|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|4.25||||4.25|2.93|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.25||||4.25|1.26|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|Self-pay|Self-pay|4.25||||4.25|1.49|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.25||||4.25|1.26|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.25||||4.25|1.26|3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.25||||4.25||3.7|1.03
1445|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.25||||4.25||3.7|1.03
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|AARP [1000]|AARP [100000]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|AETNA [1015]|AETNA [101529]|7.91||||7.91|3.49|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.91||||7.91|2.35|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|BCBS [1155]|BCBS UTHCT [115568]|7.91||||7.91|3.72|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.91||||7.91|3.96|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.91||||7.91|3.96|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.91||||7.91|4.98|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.91||||7.91|2.35|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|CIGNA [1260]|CIGNA GWH [126023]|7.91||||7.91|4.35|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.91||||7.91|5.46|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.91||||7.91|3.96|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.91||||7.91|3.49|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.91||||7.91|2.35|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.91||||7.91|3.49|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.91||||7.91|2.35|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.91||||7.91|2.35|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.91||||7.91|5.46|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.91||||7.91|2.35|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|Self-pay|Self-pay|7.91||||7.91|2.77|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.91||||7.91|2.35|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.91||||7.91|2.35|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.91||||7.91||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AARP [1000]|AARP [100000]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AARP [1000]|AARP [100000]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA [1015]|AETNA [101529]|0.27||||0.27|0.12|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA [1015]|AETNA [101529]|0.27||||0.27|0.12|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.27||||0.27|0.13|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.27||||0.27|0.13|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.27||||0.27|0.14|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.27||||0.27|0.14|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.27||||0.27|0.14|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.27||||0.27|0.14|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.27||||0.27|0.17|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.27||||0.27|0.17|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.27||||0.27|0.15|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.27||||0.27|0.15|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.27||||0.27|0.19|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.27||||0.27|0.19|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.27||||0.27|0.14|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.27||||0.27|0.14|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.27||||0.27|0.12|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.27||||0.27|0.12|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.27||||0.27|0.12|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.27||||0.27|0.12|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.27||||0.27|0.19|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.27||||0.27|0.19|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|Self-pay|Self-pay|0.27||||0.27|0.09|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|Self-pay|Self-pay|0.27||||0.27|0.09|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.27||||0.27|0.08|5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.27||||0.27||5.46|0.08
14468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 120 MG-CODEINE 12 MG/5 ML ORAL SOLUTION REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.27||||0.27||5.46|0.08
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AARP [1000]|AARP [100000]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AETNA [1015]|AETNA [101529]|105.37||||105.37|46.47|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105.37||||105.37|31.24|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BCBS UTHCT [115568]|105.37||||105.37|49.52|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105.37||||105.37|52.69|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105.37||||105.37|52.69|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105.37||||105.37|66.38|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105.37||||105.37|31.24|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|CIGNA [1260]|CIGNA GWH [126023]|105.37||||105.37|57.95|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|105.37||||105.37|72.71|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105.37||||105.37|52.69|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105.37||||105.37|46.47|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105.37||||105.37|31.24|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105.37||||105.37|46.47|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105.37||||105.37|31.24|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|105.37||||105.37|31.24|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|105.37||||105.37|72.71|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105.37||||105.37|31.24|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|Self-pay|Self-pay|105.37||||105.37|36.88|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105.37||||105.37|31.24|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105.37||||105.37|31.24|72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105.37||||105.37||72.71|31.24
14471|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DORZOLAMIDE 2 % EYE DROPS|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105.37||||105.37||72.71|31.24
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.56||||0.56|0.25|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.56||||0.56|0.17|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.56||||0.56|0.26|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.56||||0.56|0.28|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.56||||0.56|0.28|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.56||||0.56|0.35|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.56||||0.56|0.17|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.56||||0.56|0.31|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.56||||0.56|0.39|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.56||||0.56|0.28|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.56||||0.56|0.25|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.56||||0.56|0.17|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.56||||0.56|0.25|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.56||||0.56|0.17|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.56||||0.56|0.17|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.56||||0.56|0.39|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.56||||0.56|0.17|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.56||||0.56|0.2|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.56||||0.56|0.17|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.56||||0.56|0.17|0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.56||||0.56||0.39|0.17
14550|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TERAZOSIN 1 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.56||||0.56||0.39|0.17
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.01||||1.01|0.45|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.01||||1.01|0.3|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.01||||1.01|0.47|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.01||||1.01|0.51|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.01||||1.01|0.51|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.01||||1.01|0.64|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.01||||1.01|0.3|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.01||||1.01|0.56|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.01||||1.01|0.7|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.01||||1.01|0.51|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.01||||1.01|0.45|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.01||||1.01|0.3|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.01||||1.01|0.45|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.01||||1.01|0.3|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.01||||1.01|0.3|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.01||||1.01|0.7|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.01||||1.01|0.3|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|1.01||||1.01|0.35|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.01||||1.01|0.3|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.01||||1.01|0.3|0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.01||||1.01||0.7|0.3
14626|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER (SR) 180 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.01||||1.01||0.7|0.3
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.24||||0.24|0.11|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.24||||0.24|0.07|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.24||||0.24|0.11|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.24||||0.24|0.12|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.24||||0.24|0.12|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.24||||0.24|0.15|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.24||||0.24|0.07|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.24||||0.24|0.13|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.24||||0.24|0.17|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.24||||0.24|0.12|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.24||||0.24|0.11|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.24||||0.24|0.07|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.24||||0.24|0.11|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.24||||0.24|0.07|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.24||||0.24|0.07|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.24||||0.24|0.17|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.24||||0.24|0.07|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.24||||0.24|0.08|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.24||||0.24|0.07|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.24||||0.24|0.07|0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.24||||0.24||0.17|0.07
14632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAMADOL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.24||||0.24||0.17|0.07
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|1656.95||||1656.95|465.6|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1656.95||||1656.95|491.29|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|1656.95||||1656.95|778.77|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1656.95||||1656.95|0|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1656.95||||1656.95|828.48|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1656.95||||1656.95|1043.88|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1656.95||||1656.95|491.29|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|1656.95||||1656.95|828.48|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1656.95||||1656.95|1143.3|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1656.95||||1656.95|1.1|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1656.95||||1656.95|465.6|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1656.95||||1656.95|491.29|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1656.95||||1656.95|465.6|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1656.95||||1656.95|491.29|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1656.95||||1656.95|491.29|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1656.95||||1656.95|1143.3|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1656.95||||1656.95|491.29|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|1656.95||||1656.95|579.93|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1656.95||||1656.95|491.29|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1656.95||||1656.95|491.29|1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1656.95||||1656.95||1143.3|1.1
14643|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 20,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1656.95||||1656.95||1143.3|1.1
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.68||||0.68|0.3|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.68||||0.68|0.2|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.68||||0.68|0.32|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.68||||0.68|0.34|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.68||||0.68|0.34|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.68||||0.68|0.43|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.68||||0.68|0.2|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.68||||0.68|0.37|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.68||||0.68|0.47|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.68||||0.68|0.34|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.68||||0.68|0.3|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.68||||0.68|0.2|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.68||||0.68|0.3|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.68||||0.68|0.2|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.68||||0.68|0.2|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.68||||0.68|0.47|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.68||||0.68|0.2|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|Self-pay|Self-pay|0.68||||0.68|0.24|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.68||||0.68|0.2|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.68||||0.68|0.2|0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.68||||0.68||0.47|0.2
14719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 850 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.68||||0.68||0.47|0.2
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.35||||3.35|1.48|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.35||||3.35|0.99|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.35||||3.35|1.57|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.35||||3.35|1.68|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.35||||3.35|1.68|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.35||||3.35|2.11|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.35||||3.35|0.99|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.35||||3.35|1.84|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.35||||3.35|2.31|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.35||||3.35|1.68|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.35||||3.35|1.48|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.35||||3.35|0.99|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.35||||3.35|1.48|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.35||||3.35|0.99|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.35||||3.35|0.99|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.35||||3.35|2.31|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.35||||3.35|0.99|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|Self-pay|Self-pay|3.35||||3.35|1.17|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.35||||3.35|0.99|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.35||||3.35|0.99|2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.35||||3.35||2.31|0.99
14792|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TIZANIDINE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.35||||3.35||2.31|0.99
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.44||||0.44|0.19|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.44||||0.44|0.13|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.44||||0.44|0.21|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.44||||0.44|0.22|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.44||||0.44|0.22|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.44||||0.44|0.28|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.44||||0.44|0.13|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.44||||0.44|0.24|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.44||||0.44|0.3|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.44||||0.44|0.22|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.44||||0.44|0.19|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.44||||0.44|0.13|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.44||||0.44|0.19|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.44||||0.44|0.13|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.44||||0.44|0.13|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.44||||0.44|0.3|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.44||||0.44|0.13|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.44||||0.44|0.15|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.44||||0.44|0.13|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.44||||0.44|0.13|0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.44||||0.44||0.3|0.13
14823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.44||||0.44||0.3|0.13
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.59||||0.59|0.26|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.59||||0.59|0.17|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.59||||0.59|0.28|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.59||||0.59|0.3|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.59||||0.59|0.3|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.59||||0.59|0.37|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.59||||0.59|0.17|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.59||||0.59|0.32|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.59||||0.59|0.41|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.59||||0.59|0.3|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.59||||0.59|0.26|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.59||||0.59|0.17|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.59||||0.59|0.26|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.59||||0.59|0.17|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.59||||0.59|0.17|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.59||||0.59|0.41|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.59||||0.59|0.17|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.59||||0.59|0.21|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.59||||0.59|0.17|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.59||||0.59|0.17|0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.59||||0.59||0.41|0.17
14824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.59||||0.59||0.41|0.17
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|AARP [1000]|AARP [100000]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|AETNA [1015]|AETNA [101529]|40.3||||40.3|16.32|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40.3||||40.3|11.95|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|BCBS [1155]|BCBS UTHCT [115568]|40.3||||40.3|18.94|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40.3||||40.3|0|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40.3||||40.3|20.15|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40.3||||40.3|25.39|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40.3||||40.3|11.95|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|CIGNA [1260]|CIGNA GWH [126023]|40.3||||40.3|22.17|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|40.3||||40.3|27.81|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|40.3||||40.3|0.83|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40.3||||40.3|16.32|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40.3||||40.3|11.95|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40.3||||40.3|16.32|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40.3||||40.3|11.95|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|40.3||||40.3|11.95|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|40.3||||40.3|27.81|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40.3||||40.3|11.95|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|Self-pay|Self-pay|40.3||||40.3|14.1|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|40.3||||40.3|11.95|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40.3||||40.3|4.9|27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40.3||||40.3||27.81|0.83
14845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40.3||||40.3||27.81|0.83
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AARP [1000]|AARP [100000]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|18.6||||18.6|9.6|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.6||||18.6|5.51|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BCBS UTHCT [115568]|18.6||||18.6|8.74|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.6||||18.6|0|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.6||||18.6|9.3|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.6||||18.6|11.72|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.6||||18.6|5.51|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|CIGNA [1260]|CIGNA GWH [126023]|18.6||||18.6|10.23|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.6||||18.6|12.83|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.6||||18.6|0.03|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.6||||18.6|9.6|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.6||||18.6|5.51|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.6||||18.6|9.6|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.6||||18.6|5.51|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.6||||18.6|5.51|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.6||||18.6|12.83|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.6||||18.6|5.51|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|Self-pay|Self-pay|18.6||||18.6|6.51|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.6||||18.6|5.51|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.6||||18.6|5.51|12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.6||||18.6||12.83|0.03
14868|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.6||||18.6||12.83|0.03
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|4.19||||4.19|1.85|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.19||||4.19|1.24|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|4.19||||4.19|1.97|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.19||||4.19|2.1|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.19||||4.19|2.1|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.19||||4.19|2.64|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.19||||4.19|1.24|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|4.19||||4.19|2.3|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.19||||4.19|2.89|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.19||||4.19|2.1|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.19||||4.19|1.85|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.19||||4.19|1.24|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.19||||4.19|1.85|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.19||||4.19|1.24|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.19||||4.19|1.24|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.19||||4.19|2.89|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.19||||4.19|1.24|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|Self-pay|Self-pay|4.19||||4.19|1.47|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.19||||4.19|1.24|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.19||||4.19|1.24|2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.19||||4.19||2.89|1.24
14979|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.19||||4.19||2.89|1.24
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.27||||0.27|0.12|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.27||||0.27|0.08|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.27||||0.27|0.13|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.27||||0.27|0.14|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.27||||0.27|0.14|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.27||||0.27|0.17|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.27||||0.27|0.08|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.27||||0.27|0.15|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.27||||0.27|0.19|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.27||||0.27|0.14|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.27||||0.27|0.12|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.27||||0.27|0.08|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.27||||0.27|0.12|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.27||||0.27|0.08|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.27||||0.27|0.08|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.27||||0.27|0.19|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.27||||0.27|0.08|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.27||||0.27|0.09|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.27||||0.27|0.08|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.27||||0.27|0.08|0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.27||||0.27||0.19|0.08
15065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMOTIDINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.27||||0.27||0.19|0.08
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.42||||1.42|0.98|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.42||||1.42|0.42|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.42||||1.42|0.67|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.42||||1.42|0|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.42||||1.42|0.71|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.42||||1.42|0.89|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.42||||1.42|0.42|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.42||||1.42|0.78|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.42||||1.42|0.98|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.42||||1.42|0.6|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.42||||1.42|0.98|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.42||||1.42|0.42|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.42||||1.42|0.98|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.42||||1.42|0.42|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.42||||1.42|0.42|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.42||||1.42|0.98|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.42||||1.42|0.42|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.42||||1.42|0.5|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.42||||1.42|0.42|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.42||||1.42|0.42|0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.42||||1.42||0.98|0.42
15113|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.42||||1.42||0.98|0.42
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|AARP [1000]|AARP [100000]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|AETNA [1015]|AETNA [101529]|399.9||||399.9|176.36|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|399.9||||399.9|118.57|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|BCBS [1155]|BCBS UTHCT [115568]|399.9||||399.9|187.95|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|399.9||||399.9|199.95|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|399.9||||399.9|199.95|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|399.9||||399.9|251.94|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|399.9||||399.9|118.57|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|CIGNA [1260]|CIGNA GWH [126023]|399.9||||399.9|219.95|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|399.9||||399.9|275.93|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|399.9||||399.9|199.95|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|399.9||||399.9|176.36|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|399.9||||399.9|118.57|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|399.9||||399.9|176.36|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|399.9||||399.9|118.57|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|399.9||||399.9|118.57|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|399.9||||399.9|275.93|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|399.9||||399.9|118.57|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|Self-pay|Self-pay|399.9||||399.9|139.96|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|399.9||||399.9|118.57|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|399.9||||399.9|118.57|275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|399.9||||399.9||275.93|118.57
15119|ERX|0250 - PHARMACY-GENERAL|SEVOFLURANE INHALATION LIQUID|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|399.9||||399.9||275.93|118.57
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|1236.9||||1236.9|1015.01|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1236.9||||1236.9|366.74|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|1236.9||||1236.9|581.34|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1236.9||||1236.9|0|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1236.9||||1236.9|618.45|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1236.9||||1236.9|779.25|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1236.9||||1236.9|366.74|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|1236.9||||1236.9|618.45|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1236.9||||1236.9|853.46|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1236.9||||1236.9|244.98|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1236.9||||1236.9|1015.01|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1236.9||||1236.9|366.74|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1236.9||||1236.9|1015.01|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1236.9||||1236.9|366.74|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|1236.9||||1236.9|366.74|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1236.9||||1236.9|853.46|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1236.9||||1236.9|366.74|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|1236.9||||1236.9|432.91|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1236.9||||1236.9|366.74|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1236.9||||1236.9|366.74|1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1236.9||||1236.9||1015.01|244.98
15157|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1236.9||||1236.9||1015.01|244.98
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.5||||5.5|2.43|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.5||||5.5|1.63|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.5||||5.5|2.59|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.5||||5.5|2.75|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.5||||5.5|2.75|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.5||||5.5|3.47|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.5||||5.5|1.63|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.5||||5.5|3.03|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.5||||5.5|3.8|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.5||||5.5|2.75|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.5||||5.5|2.43|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.5||||5.5|1.63|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.5||||5.5|2.43|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.5||||5.5|1.63|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.5||||5.5|1.63|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.5||||5.5|3.8|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.5||||5.5|1.63|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|Self-pay|Self-pay|5.5||||5.5|1.92|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.5||||5.5|1.63|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.5||||5.5|1.63|3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.5||||5.5||3.8|1.63
15327|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SUMATRIPTAN 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.5||||5.5||3.8|1.63
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|0.88||||0.88|0.39|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.88||||0.88|0.26|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.88||||0.88|0.41|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.88||||0.88|0.44|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.88||||0.88|0.44|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.88||||0.88|0.55|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.88||||0.88|0.26|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.88||||0.88|0.48|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.88||||0.88|0.61|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.88||||0.88|0.44|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.88||||0.88|0.39|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.88||||0.88|0.26|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.88||||0.88|0.39|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.88||||0.88|0.26|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.88||||0.88|0.26|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.88||||0.88|0.61|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.88||||0.88|0.26|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|0.88||||0.88|0.31|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.88||||0.88|0.26|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.88||||0.88|0.26|0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.88||||0.88||0.61|0.26
15341|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC SODIUM 75 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.88||||0.88||0.61|0.26
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.42||||0.42|0.19|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.42||||0.42|0.12|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.42||||0.42|0.2|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.42||||0.42|0.21|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.42||||0.42|0.21|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.42||||0.42|0.26|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.42||||0.42|0.12|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.42||||0.42|0.23|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.42||||0.42|0.29|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.42||||0.42|0.21|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.42||||0.42|0.19|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.42||||0.42|0.12|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.42||||0.42|0.19|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.42||||0.42|0.12|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.42||||0.42|0.12|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.42||||0.42|0.29|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.42||||0.42|0.12|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.42||||0.42|0.15|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.42||||0.42|0.12|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.42||||0.42|0.12|0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.42||||0.42||0.29|0.12
15349|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.42||||0.42||0.29|0.12
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|AARP [1000]|AARP [100000]|74.4||||74.4|34.28|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.4||||74.4||51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|AETNA [1015]|AETNA [101529]|74.4||||74.4|30.53|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.4||||74.4|22.06|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.4||||74.4||51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.4||||74.4||51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|BCBS [1155]|BCBS UTHCT [115568]|74.4||||74.4|34.97|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.4||||74.4|0|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.4||||74.4|37.2|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.4||||74.4|46.87|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.4||||74.4|22.06|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.4||||74.4||51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|CIGNA [1260]|CIGNA GWH [126023]|74.4||||74.4|40.92|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|74.4||||74.4|51.34|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.4||||74.4|3.41|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.4||||74.4||51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.4||||74.4|30.53|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.4||||74.4|22.06|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.4||||74.4||51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.4||||74.4|30.53|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.4||||74.4|22.06|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.4||||74.4|22.06|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|74.4||||74.4|51.34|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.4||||74.4|22.06|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|Self-pay|Self-pay|74.4||||74.4|26.04|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.4||||74.4|22.06|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.4||||74.4|22.06|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.4||||74.4|34.28|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.4||||74.4||51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.4||||74.4||51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.4||||74.4|34.28|51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.4||||74.4||51.34|3.41
15426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION|200 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.4||||74.4||51.34|3.41
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|3.54||||3.54|1.56|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|3.54||||3.54|1.56|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|3.54||||3.54|1.66|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|3.54||||3.54|1.66|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.54||||3.54|1.77|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.54||||3.54|1.77|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.54||||3.54|1.77|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.54||||3.54|1.77|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.54||||3.54|2.23|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.54||||3.54|2.23|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|3.54||||3.54|1.95|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|3.54||||3.54|1.95|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.54||||3.54|2.44|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.54||||3.54|2.44|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.54||||3.54|1.77|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.54||||3.54|1.77|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.54||||3.54|1.56|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.54||||3.54|1.56|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.54||||3.54|1.56|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.54||||3.54|1.56|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.54||||3.54|2.44|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.54||||3.54|2.44|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|Self-pay|Self-pay|3.54||||3.54|1.24|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|Self-pay|Self-pay|3.54||||3.54|1.24|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.54||||3.54|1.05|2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.54||||3.54||2.44|1.05
15706|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.54||||3.54||2.44|1.05
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AARP [1000]|AARP [100000]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AETNA [1015]|AETNA [101529]|232.1||||232.1|102.36|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|232.1||||232.1|68.82|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS [1155]|BCBS UTHCT [115568]|232.1||||232.1|109.09|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|232.1||||232.1|116.05|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|232.1||||232.1|116.05|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|232.1||||232.1|146.22|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|232.1||||232.1|68.82|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|CIGNA [1260]|CIGNA GWH [126023]|232.1||||232.1|127.66|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|232.1||||232.1|160.15|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|232.1||||232.1|116.05|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|232.1||||232.1|102.36|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|232.1||||232.1|68.82|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|232.1||||232.1|102.36|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|232.1||||232.1|68.82|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|232.1||||232.1|68.82|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|232.1||||232.1|160.15|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|232.1||||232.1|68.82|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|Self-pay|Self-pay|232.1||||232.1|81.23|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|232.1||||232.1|68.82|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|232.1||||232.1|68.82|160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|232.1||||232.1||160.15|68.82
15738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITONIN (SALMON) 200 UNIT/ACTUATION NASAL SPRAY|3.7 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|232.1||||232.1||160.15|68.82
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.9||||0.9|0.4|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.9||||0.9|0.27|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.9||||0.9|0.42|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.9||||0.9|0.45|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.9||||0.9|0.45|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.9||||0.9|0.57|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.9||||0.9|0.27|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.9||||0.9|0.5|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.9||||0.9|0.62|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.9||||0.9|0.45|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.9||||0.9|0.4|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.9||||0.9|0.27|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.9||||0.9|0.4|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.9||||0.9|0.27|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.9||||0.9|0.27|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.9||||0.9|0.62|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.9||||0.9|0.27|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.9||||0.9|0.31|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.9||||0.9|0.27|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.9||||0.9|0.27|0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.9||||0.9||0.62|0.27
15746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BICALUTAMIDE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.9||||0.9||0.62|0.27
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.26||||0.26|0.11|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.26||||0.26|0.08|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.26||||0.26|0.12|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.26||||0.26|0.13|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.26||||0.26|0.13|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.26||||0.26|0.16|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.26||||0.26|0.08|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.26||||0.26|0.14|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.26||||0.26|0.18|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.26||||0.26|0.13|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.26||||0.26|0.11|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.26||||0.26|0.08|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.26||||0.26|0.11|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.26||||0.26|0.08|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.26||||0.26|0.08|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.26||||0.26|0.18|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.26||||0.26|0.08|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|Self-pay|Self-pay|0.26||||0.26|0.09|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.26||||0.26|0.08|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.26||||0.26|0.08|0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.26||||0.26||0.18|0.08
15747|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 6.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.26||||0.26|0.11|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.26||||0.26|0.08|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.26||||0.26|0.12|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.26||||0.26|0.13|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.26||||0.26|0.13|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.26||||0.26|0.16|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.26||||0.26|0.08|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.26||||0.26|0.14|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.26||||0.26|0.18|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.26||||0.26|0.13|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.26||||0.26|0.11|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.26||||0.26|0.08|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.26||||0.26|0.11|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.26||||0.26|0.08|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.26||||0.26|0.08|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.26||||0.26|0.18|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.26||||0.26|0.08|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.26||||0.26|0.09|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.26||||0.26|0.08|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.26||||0.26|0.08|0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.26||||0.26||0.18|0.08
15749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.26||||0.26||0.18|0.08
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|AARP [1000]|AARP [100000]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|AETNA [1015]|AETNA [101529]|27.04||||27.04|11.92|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.04||||27.04|8.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|27.04||||27.04|12.71|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.04||||27.04|13.52|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.04||||27.04|13.52|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.04||||27.04|17.04|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.04||||27.04|8.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|27.04||||27.04|14.87|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.04||||27.04|18.66|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.04||||27.04|13.52|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.04||||27.04|11.92|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.04||||27.04|8.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.04||||27.04|11.92|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.04||||27.04|8.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.04||||27.04|8.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.04||||27.04|18.66|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.04||||27.04|8.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|Self-pay|Self-pay|27.04||||27.04|9.46|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.04||||27.04|8.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.04||||27.04|8.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.04||||27.04||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|AARP [1000]|AARP [100000]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|AETNA [1015]|AETNA [101529]|33.79||||33.79|14.9|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.79||||33.79|10.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|BCBS [1155]|BCBS UTHCT [115568]|33.79||||33.79|15.88|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.79||||33.79|16.9|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.79||||33.79|16.9|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.79||||33.79|21.29|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.79||||33.79|10.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|CIGNA [1260]|CIGNA GWH [126023]|33.79||||33.79|18.58|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33.79||||33.79|23.32|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.79||||33.79|16.9|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.79||||33.79|14.9|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.79||||33.79|10.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.79||||33.79|14.9|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.79||||33.79|10.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.79||||33.79|10.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33.79||||33.79|23.32|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.79||||33.79|10.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|Self-pay|Self-pay|33.79||||33.79|11.83|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.79||||33.79|10.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.79||||33.79|10.02|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|12.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.79||||33.79||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|AARP [1000]|AARP [100000]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|AETNA [1015]|AETNA [101529]|81.1||||81.1|35.77|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81.1||||81.1|24.05|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|81.1||||81.1|38.12|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81.1||||81.1|40.55|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81.1||||81.1|40.55|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81.1||||81.1|51.09|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81.1||||81.1|24.05|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|81.1||||81.1|44.61|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|81.1||||81.1|55.96|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|81.1||||81.1|40.55|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81.1||||81.1|35.77|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81.1||||81.1|24.05|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81.1||||81.1|35.77|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|81.1||||81.1|24.05|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|81.1||||81.1|24.05|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|81.1||||81.1|55.96|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81.1||||81.1|24.05|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|Self-pay|Self-pay|81.1||||81.1|28.38|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|81.1||||81.1|24.05|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81.1||||81.1|24.05|55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81.1||||81.1||55.96|8.02
15797|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 200 MG/5 ML ORAL SUSPENSION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|81.1||||81.1||55.96|8.02
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AARP [1000]|AARP [100000]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AETNA [1015]|AETNA [101529]|46.5||||46.5|15|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.5||||46.5|13.79|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS [1155]|BCBS UTHCT [115568]|46.5||||46.5|21.86|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.5||||46.5|0|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.5||||46.5|23.25|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.5||||46.5|29.3|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.5||||46.5|13.79|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|CIGNA [1260]|CIGNA GWH [126023]|46.5||||46.5|25.58|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|46.5||||46.5|32.09|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|46.5||||46.5|0.4|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.5||||46.5|15|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.5||||46.5|13.79|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.5||||46.5|15|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.5||||46.5|13.79|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|46.5||||46.5|13.79|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|46.5||||46.5|32.09|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.5||||46.5|13.79|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|Self-pay|Self-pay|46.5||||46.5|16.27|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|46.5||||46.5|13.79|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.5||||46.5|13.79|32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.5||||46.5||32.09|0.4
15845|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 25,000 UNIT/500 ML (50 UNIT/ML) IN DEXTROSE 5 % IV|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.5||||46.5||32.09|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|AARP [1000]|AARP [100000]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|AETNA [1015]|AETNA [101529]|17.05||||17.05|0.6|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.05||||17.05|5.06|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|BCBS [1155]|BCBS UTHCT [115568]|17.05||||17.05|8.01|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.05||||17.05|0|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.05||||17.05|8.53|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.05||||17.05|10.74|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.05||||17.05|5.06|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|CIGNA [1260]|CIGNA GWH [126023]|17.05||||17.05|9.38|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.05||||17.05|11.76|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.05||||17.05|0.4|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.05||||17.05|0.6|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.05||||17.05|5.06|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.05||||17.05|0.6|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.05||||17.05|5.06|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.05||||17.05|5.06|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.05||||17.05|11.76|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.05||||17.05|5.06|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|Self-pay|Self-pay|17.05||||17.05|5.97|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.05||||17.05|5.06|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.05||||17.05|5.06|11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.05||||17.05||11.76|0.4
15847|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) (PF) 1,000 UNIT/500 ML IN 0.9 % SODIUM CHLORIDE IV - CATH FLUSH|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.05||||17.05||11.76|0.4
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|AARP [1000]|AARP [100000]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|AETNA [1015]|AETNA [101529]|58.13||||58.13|25.64|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58.13||||58.13|17.24|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|BCBS [1155]|BCBS UTHCT [115568]|58.13||||58.13|27.32|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58.13||||58.13|29.07|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58.13||||58.13|29.07|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58.13||||58.13|36.62|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58.13||||58.13|17.24|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|CIGNA [1260]|CIGNA GWH [126023]|58.13||||58.13|31.97|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|58.13||||58.13|40.11|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58.13||||58.13|29.07|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58.13||||58.13|25.64|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58.13||||58.13|17.24|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58.13||||58.13|25.64|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.13||||58.13|17.24|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|58.13||||58.13|17.24|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|58.13||||58.13|40.11|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58.13||||58.13|17.24|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|Self-pay|Self-pay|58.13||||58.13|20.35|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58.13||||58.13|17.24|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58.13||||58.13|17.24|40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58.13||||58.13||40.11|17.24
15858|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 25 MG/250 ML (100 MCG/ML) IN 5 % DEXTROSE  INTRAVENOUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58.13||||58.13||40.11|17.24
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|23.25||||23.25|10.25|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.25||||23.25|6.89|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|23.25||||23.25|10.93|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.25||||23.25|11.63|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.25||||23.25|11.63|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.25||||23.25|14.65|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.25||||23.25|6.89|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|23.25||||23.25|12.79|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|23.25||||23.25|16.04|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.25||||23.25|11.63|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.25||||23.25|10.25|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.25||||23.25|6.89|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.25||||23.25|10.25|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.25||||23.25|6.89|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.25||||23.25|6.89|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|23.25||||23.25|16.04|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.25||||23.25|6.89|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|Self-pay|Self-pay|23.25||||23.25|8.14|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.25||||23.25|6.89|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.25||||23.25|6.89|16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.25||||23.25||16.04|6.89
15880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LAMIVUDINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.25||||23.25||16.04|6.89
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AARP [1000]|AARP [100000]|63.55||||63.55|8.39|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63.55||||63.55||43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AETNA [1015]|AETNA [101529]|63.55||||63.55|14.3|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63.55||||63.55|18.84|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63.55||||63.55||43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63.55||||63.55||43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BCBS UTHCT [115568]|63.55||||63.55|29.87|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63.55||||63.55|0|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63.55||||63.55|31.78|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63.55||||63.55|40.04|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63.55||||63.55|18.84|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63.55||||63.55||43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|CIGNA [1260]|CIGNA GWH [126023]|63.55||||63.55|34.95|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|63.55||||63.55|43.85|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63.55||||63.55|8.99|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63.55||||63.55||43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63.55||||63.55|14.3|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63.55||||63.55|18.84|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63.55||||63.55||43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63.55||||63.55|14.3|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63.55||||63.55|18.84|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|63.55||||63.55|18.84|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|63.55||||63.55|43.85|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63.55||||63.55|18.84|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|Self-pay|Self-pay|63.55||||63.55|22.24|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63.55||||63.55|18.84|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63.55||||63.55|18.84|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63.55||||63.55|8.39|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63.55||||63.55||43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63.55||||63.55||43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63.55||||63.55|8.39|43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63.55||||63.55||43.85|8.39
15981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/250 ML (1 MG/ML) IN 5 % DEXTROSE INTRAVENOUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63.55||||63.55||43.85|8.39
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.06||||4.06|1.79|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.06||||4.06|1.2|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.06||||4.06|1.91|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.06||||4.06|2.03|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.06||||4.06|2.03|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.06||||4.06|2.56|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.06||||4.06|1.2|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.06||||4.06|2.23|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.06||||4.06|2.8|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.06||||4.06|2.03|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.06||||4.06|1.79|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.06||||4.06|1.2|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.06||||4.06|1.79|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.06||||4.06|1.2|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.06||||4.06|1.2|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.06||||4.06|2.8|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.06||||4.06|1.2|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|Self-pay|Self-pay|4.06||||4.06|1.42|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.06||||4.06|1.2|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.06||||4.06|1.2|2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.06||||4.06||2.8|1.2
16052|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.06||||4.06||2.8|1.2
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AARP [1000]|AARP [100000]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AETNA [1015]|AETNA [101529]|111.6||||111.6|49.22|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111.6||||111.6|33.09|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS [1155]|BCBS UTHCT [115568]|111.6||||111.6|52.45|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111.6||||111.6|55.8|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111.6||||111.6|55.8|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111.6||||111.6|70.31|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111.6||||111.6|33.09|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|CIGNA [1260]|CIGNA GWH [126023]|111.6||||111.6|61.38|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|111.6||||111.6|77|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|111.6||||111.6|55.8|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111.6||||111.6|49.22|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111.6||||111.6|33.09|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111.6||||111.6|49.22|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111.6||||111.6|33.09|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|111.6||||111.6|33.09|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|111.6||||111.6|77|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111.6||||111.6|33.09|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|Self-pay|Self-pay|111.6||||111.6|39.06|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|111.6||||111.6|33.09|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111.6||||111.6|33.09|77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111.6||||111.6||77|33.09
16070|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM BROMIDE 21 MCG (0.03 %) NASAL SPRAY|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111.6||||111.6||77|33.09
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.65||||1.65|0.73|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.65||||1.65|0.49|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.65||||1.65|0.78|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.65||||1.65|0.83|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.65||||1.65|0.83|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.65||||1.65|1.04|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.65||||1.65|0.49|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.65||||1.65|0.91|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.65||||1.65|1.14|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.65||||1.65|0.83|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.65||||1.65|0.73|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.65||||1.65|0.49|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.65||||1.65|0.73|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.65||||1.65|0.49|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.65||||1.65|0.49|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.65||||1.65|1.14|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.65||||1.65|0.49|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|Self-pay|Self-pay|1.65||||1.65|0.58|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.65||||1.65|0.49|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.65||||1.65|0.49|1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.65||||1.65||1.14|0.49
16081|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.65||||1.65||1.14|0.49
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.14||||1.14|0.5|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.14||||1.14|0.34|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.14||||1.14|0.54|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.14||||1.14|0.57|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.14||||1.14|0.57|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.14||||1.14|0.72|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.14||||1.14|0.34|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.14||||1.14|0.63|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.14||||1.14|0.79|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.14||||1.14|0.57|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.14||||1.14|0.5|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.14||||1.14|0.34|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.14||||1.14|0.5|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.14||||1.14|0.34|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.14||||1.14|0.34|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.14||||1.14|0.79|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.14||||1.14|0.34|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|Self-pay|Self-pay|1.14||||1.14|0.4|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.14||||1.14|0.34|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.14||||1.14|0.34|0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.14||||1.14||0.79|0.34
16082|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FAMCICLOVIR 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.14||||1.14||0.79|0.34
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|25.11||||25.11|3.22|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.11||||25.11||17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|25.11||||25.11|3.07|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.11||||25.11|7.45|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.11||||25.11||17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.11||||25.11||17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BCBS UTHCT [115568]|25.11||||25.11|11.8|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.11||||25.11|0|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.11||||25.11|12.56|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.11||||25.11|15.82|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.11||||25.11|7.45|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.11||||25.11||17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA GWH [126023]|25.11||||25.11|13.81|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|25.11||||25.11|17.33|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25.11||||25.11|0.79|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.11||||25.11||17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.11||||25.11|3.07|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.11||||25.11|7.45|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.11||||25.11||17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.11||||25.11|3.07|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.11||||25.11|7.45|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|25.11||||25.11|7.45|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.11||||25.11|17.33|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.11||||25.11|7.45|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|25.11||||25.11|8.79|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25.11||||25.11|7.45|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.11||||25.11|7.45|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.11||||25.11|3.22|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25.11||||25.11||17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25.11||||25.11||17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.11||||25.11|3.22|17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.11||||25.11||17.33|0.79
16162|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 1 GRAM/100 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.11||||25.11||17.33|0.79
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.93||||0.93|0.41|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.93||||0.93|0.28|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.93||||0.93|0.44|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.93||||0.93|0.47|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.93||||0.93|0.47|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.93||||0.93|0.59|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.93||||0.93|0.28|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.93||||0.93|0.51|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.93||||0.93|0.64|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.93||||0.93|0.47|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.93||||0.93|0.41|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.93||||0.93|0.28|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.93||||0.93|0.41|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.93||||0.93|0.28|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.93||||0.93|0.28|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.93||||0.93|0.64|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.93||||0.93|0.28|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.93||||0.93|0.33|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.93||||0.93|0.28|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.93||||0.93|0.28|0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.93||||0.93||0.64|0.28
16205|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANASTROZOLE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.93||||0.93||0.64|0.28
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|AARP [1000]|AARP [100000]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|AETNA [1015]|AETNA [101529]|29.6||||29.6|13.05|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|BCBS [1155]|BCBS UTHCT [115568]|29.6||||29.6|13.91|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.6||||29.6|14.8|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.6||||29.6|14.8|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.6||||29.6|18.65|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|CIGNA [1260]|CIGNA GWH [126023]|29.6||||29.6|16.28|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|29.6||||29.6|20.42|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29.6||||29.6|14.8|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.6||||29.6|13.05|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.6||||29.6|13.05|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|29.6||||29.6|20.42|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|Self-pay|Self-pay|29.6||||29.6|10.36|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|0.25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|AARP [1000]|AARP [100000]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|29.6||||29.6|13.05|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|29.6||||29.6|13.91|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.6||||29.6|14.8|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.6||||29.6|14.8|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.6||||29.6|18.65|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|29.6||||29.6|16.28|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|29.6||||29.6|20.42|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29.6||||29.6|14.8|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.6||||29.6|13.05|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.6||||29.6|13.05|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|29.6||||29.6|20.42|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|Self-pay|Self-pay|29.6||||29.6|10.36|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.6||||29.6|8.78|20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.6||||29.6||20.42|8.78
16218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 1 MCG/ML ORAL SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.6||||29.6||20.42|8.78
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.23||||0.23|0.1|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.23||||0.23|0.07|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.23||||0.23|0.11|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.23||||0.23|0.12|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.23||||0.23|0.12|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.23||||0.23|0.14|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.23||||0.23|0.07|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.23||||0.23|0.13|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.23||||0.23|0.16|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.23||||0.23|0.12|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.23||||0.23|0.1|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.23||||0.23|0.07|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.23||||0.23|0.1|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.23||||0.23|0.07|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.23||||0.23|0.07|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.23||||0.23|0.16|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.23||||0.23|0.07|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.23||||0.23|0.08|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.23||||0.23|0.07|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.23||||0.23|0.07|0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.23||||0.23||0.16|0.07
1622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.23||||0.23||0.16|0.07
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.65||||1.65|0.73|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.65||||1.65|0.49|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.65||||1.65|0.78|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.65||||1.65|0.83|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.65||||1.65|0.83|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.65||||1.65|1.04|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.65||||1.65|0.49|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.65||||1.65|0.91|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.65||||1.65|1.14|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.65||||1.65|0.83|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.65||||1.65|0.73|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.65||||1.65|0.49|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.65||||1.65|0.73|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.65||||1.65|0.49|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.65||||1.65|0.49|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.65||||1.65|1.14|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.65||||1.65|0.49|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.65||||1.65|0.58|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.65||||1.65|0.49|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.65||||1.65|0.49|1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.65||||1.65||1.14|0.49
1623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.65||||1.65||1.14|0.49
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2||||2|0.88|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2||||2|0.59|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|2||||2|0.94|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2||||2|1|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2||||2|1|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2||||2|1.26|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2||||2|0.59|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|2||||2|1.1|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2||||2|1.38|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2||||2|1|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2||||2|0.88|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2||||2|0.59|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2||||2|0.88|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2||||2|0.59|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|2||||2|0.59|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2||||2|1.38|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2||||2|0.59|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|Self-pay|Self-pay|2||||2|0.7|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2||||2|0.59|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2||||2|0.59|1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2||||2||1.38|0.59
1624|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORDIAZEPOXIDE 5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2||||2||1.38|0.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|AARP [1000]|AARP [100000]|6492.71||||6492.71|3246.36|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6492.71||||6492.71|1591.4|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|AETNA [1015]|AETNA [101529]|6492.71||||6492.71|3630.96|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6492.71||||6492.71|1925.09|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6492.71||||6492.71|1575.64|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6492.71||||6492.71|1575.64|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|BCBS [1155]|BCBS UTHCT [115568]|6492.71||||6492.71|3051.57|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6492.71||||6492.71|0|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6492.71||||6492.71|3246.36|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6492.71||||6492.71|4090.41|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6492.71||||6492.71|1925.09|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6492.71||||6492.71|1575.64|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|CIGNA [1260]|CIGNA GWH [126023]|6492.71||||6492.71|3246.36|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|6492.71||||6492.71|4479.97|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6492.71||||6492.71|626.59|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6492.71||||6492.71|1575.64|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6492.71||||6492.71|3630.96|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6492.71||||6492.71|1925.09|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6492.71||||6492.71|1575.64|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6492.71||||6492.71|3630.96|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6492.71||||6492.71|1925.09|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|6492.71||||6492.71|1925.09|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|6492.71||||6492.71|4479.97|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6492.71||||6492.71|1925.09|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|Self-pay|Self-pay|6492.71||||6492.71|2272.45|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6492.71||||6492.71|1925.09|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6492.71||||6492.71|1925.09|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6492.71||||6492.71|3246.36|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6492.71||||6492.71|1575.64|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6492.71||||6492.71|1575.64|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6492.71||||6492.71|3246.36|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6492.71||||6492.71|1575.64|4479.97|626.59
16254|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GOSERELIN 10.8 MG SUBCUTANEOUS IMPLANT|10.8 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6492.71||||6492.71|3151.28|4479.97|626.59
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AARP [1000]|AARP [100000]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AETNA [1015]|AETNA [101529]|5.47||||5.47|2.41|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.47||||5.47|1.62|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS [1155]|BCBS UTHCT [115568]|5.47||||5.47|2.57|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.47||||5.47|2.74|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.47||||5.47|2.74|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.47||||5.47|3.45|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.47||||5.47|1.62|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|CIGNA [1260]|CIGNA GWH [126023]|5.47||||5.47|3.01|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|GROUP PENSION ADMIN [1450]|GPA [145000]|5.47||||5.47|3.77|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.47||||5.47|2.74|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.47||||5.47|2.41|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.47||||5.47|1.62|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.47||||5.47|2.41|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.47||||5.47|1.62|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.47||||5.47|1.62|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|PHCS [1780]|PHCS MULTIPLAN [178000]|5.47||||5.47|3.77|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.47||||5.47|1.62|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|Self-pay|Self-pay|5.47||||5.47|1.91|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.47||||5.47|1.62|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.47||||5.47|1.62|3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.47||||5.47||3.77|1.62
16299|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE-ZINC ACETATE 2 %-0.1 % TOPICAL CREAM|28 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.47||||5.47||3.77|1.62
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AARP [1000]|AARP [100000]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AETNA [1015]|AETNA [101529]|0.71||||0.71|0.31|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.71||||0.71|0.21|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.71||||0.71|0.33|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.71||||0.71|0.36|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.71||||0.71|0.36|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.71||||0.71|0.45|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.71||||0.71|0.21|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.71||||0.71|0.39|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.71||||0.71|0.49|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.71||||0.71|0.36|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.71||||0.71|0.31|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.71||||0.71|0.21|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.71||||0.71|0.31|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.71||||0.71|0.21|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.71||||0.71|0.21|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.71||||0.71|0.49|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.71||||0.71|0.21|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|Self-pay|Self-pay|0.71||||0.71|0.25|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.71||||0.71|0.21|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.71||||0.71|0.21|0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.71||||0.71||0.49|0.21
16355|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 1 MG TABLET|2 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.71||||0.71||0.49|0.21
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.36||||1.36|0.6|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.36||||1.36|0.4|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.36||||1.36|0.64|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.36||||1.36|0.68|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.36||||1.36|0.68|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.36||||1.36|0.86|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.36||||1.36|0.4|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.36||||1.36|0.75|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.36||||1.36|0.94|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.36||||1.36|0.68|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.36||||1.36|0.6|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.36||||1.36|0.4|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.36||||1.36|0.6|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.36||||1.36|0.4|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.36||||1.36|0.4|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.36||||1.36|0.94|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.36||||1.36|0.4|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|Self-pay|Self-pay|1.36||||1.36|0.48|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.36||||1.36|0.4|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.36||||1.36|0.4|0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.36||||1.36||0.94|0.4
16356|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIMEPIRIDE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.36||||1.36||0.94|0.4
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|18.6||||18.6|9.26|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.6||||18.6|5.51|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BCBS UTHCT [115568]|18.6||||18.6|8.74|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.6||||18.6|0|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.6||||18.6|9.3|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.6||||18.6|11.72|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.6||||18.6|5.51|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA GWH [126023]|18.6||||18.6|10.23|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|18.6||||18.6|12.83|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.6||||18.6|2.26|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.6||||18.6|9.26|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.6||||18.6|5.51|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.6||||18.6|9.26|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.6||||18.6|5.51|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.6||||18.6|5.51|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|18.6||||18.6|12.83|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.6||||18.6|5.51|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|18.6||||18.6|6.51|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.6||||18.6|5.51|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.6||||18.6|5.51|12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.6||||18.6||12.83|2.26
16369|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.6||||18.6||12.83|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|30.38||||30.38|18.53|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.38||||30.38|9.01|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BCBS UTHCT [115568]|30.38||||30.38|14.28|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.38||||30.38|0|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.38||||30.38|15.19|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.38||||30.38|19.14|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.38||||30.38|9.01|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA GWH [126023]|30.38||||30.38|16.71|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|30.38||||30.38|20.96|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.38||||30.38|2.26|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.38||||30.38|18.53|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.38||||30.38|9.01|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.38||||30.38|18.53|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.38||||30.38|9.01|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.38||||30.38|9.01|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|30.38||||30.38|20.96|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.38||||30.38|9.01|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|30.38||||30.38|10.63|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.38||||30.38|9.01|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.38||||30.38|9.01|20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.38||||30.38||20.96|2.26
16371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFEPIME 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.38||||30.38||20.96|2.26
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|AARP [1000]|AARP [100000]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|AETNA [1015]|AETNA [101529]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|BCBS [1155]|BCBS UTHCT [115568]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|CIGNA [1260]|CIGNA GWH [126023]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|Self-pay|Self-pay|2625||||2625|918.75|918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2625||||2625||918.75|918.75
16400000|EAP|0164 - ROOM & BOARD-OTHER-STERILE ENVIRONMENT|HC ISOLATION ROOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2625||||2625||918.75|918.75
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|131||||131|57.77|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|131||||131|38.84|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|131||||131|61.57|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|131||||131|65.5|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|131||||131|65.5|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|131||||131|82.53|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|131||||131|38.84|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|131||||131|72.05|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|131||||131|90.39|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|131||||131|65.5|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|131||||131|57.77|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|131||||131|38.84|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|131||||131|57.77|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|131||||131|38.84|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|131||||131|38.84|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|131||||131|90.39|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|131||||131|38.84|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|131||||131|45.85|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|131||||131|38.84|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|131||||131|38.84|90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|131||||131||90.39|38.84
164385|ERX|0250 - PHARMACY-GENERAL|CARIPRAZINE 1.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|131||||131||90.39|38.84
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.03||||0.03|0.02|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.03||||0.03|0.02|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.03||||0.03|0.02|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.03||||0.03|0.02|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.03||||0.03|0.02|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.03||||0.03|0.02|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.03||||0.03|0.02|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|Self-pay|Self-pay|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.03||||0.03|0.01|0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.03||||0.03||0.02|0.01
1645|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPHENIRAMINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.03||||0.03||0.02|0.01
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|29356.57||||29356.57|14678.29|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29356.57||||29356.57|9665.58|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|29356.57||||29356.57|22605.12|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29356.57||||29356.57|8704.22|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29356.57||||29356.57|9569.88|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29356.57||||29356.57|9569.88|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|29356.57||||29356.57|13797.59|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29356.57||||29356.57|0|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29356.57||||29356.57|14678.29|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29356.57||||29356.57|18494.64|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29356.57||||29356.57|8704.22|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29356.57||||29356.57|9569.88|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|29356.57||||29356.57|14678.29|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|29356.57||||29356.57|20256.03|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29356.57||||29356.57|97.73|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29356.57||||29356.57|9569.88|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29356.57||||29356.57|22605.12|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29356.57||||29356.57|8704.22|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29356.57||||29356.57|9569.88|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29356.57||||29356.57|22605.12|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29356.57||||29356.57|8704.22|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29356.57||||29356.57|8704.22|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|29356.57||||29356.57|20256.03|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29356.57||||29356.57|8704.22|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|29356.57||||29356.57|10274.8|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29356.57||||29356.57|8704.22|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29356.57||||29356.57|8704.22|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29356.57||||29356.57|14678.29|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29356.57||||29356.57|9569.88|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29356.57||||29356.57|9569.88|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29356.57||||29356.57|14678.29|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29356.57||||29356.57|9569.88|22605.12|97.73
165100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 1,200 MG/20 ML (60 MG/ML) INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29356.57||||29356.57|19139.76|22605.12|97.73
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AARP [1000]|AARP [100000]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AETNA [1015]|AETNA [101529]|12.03||||12.03|5.31|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.03||||12.03|3.57|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|12.03||||12.03|5.65|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.03||||12.03|6.02|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.03||||12.03|6.02|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.03||||12.03|7.58|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.03||||12.03|3.57|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|12.03||||12.03|6.62|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|12.03||||12.03|8.3|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.03||||12.03|6.02|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.03||||12.03|5.31|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.03||||12.03|3.57|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.03||||12.03|5.31|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.03||||12.03|3.57|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.03||||12.03|3.57|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|12.03||||12.03|8.3|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.03||||12.03|3.57|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|Self-pay|Self-pay|12.03||||12.03|4.21|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.03||||12.03|3.57|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.03||||12.03|3.57|8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.03||||12.03||8.3|3.57
165150|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 400 MG CAPSULE (WITH DELAYED RELEASE TABLETS INSIDE)|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.03||||12.03||8.3|3.57
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|3997.64||||3997.64|1254.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3997.64||||3997.64|1245.42|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|3997.64||||3997.64|2805.84|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3997.64||||3997.64|1185.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3997.64||||3997.64|1233.09|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3997.64||||3997.64|1233.09|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|3997.64||||3997.64|1878.89|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3997.64||||3997.64|0|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3997.64||||3997.64|1998.82|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3997.64||||3997.64|2518.51|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3997.64||||3997.64|1185.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3997.64||||3997.64|1233.09|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|3997.64||||3997.64|1998.82|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3997.64||||3997.64|2758.37|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3997.64||||3997.64|49.19|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3997.64||||3997.64|1233.09|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3997.64||||3997.64|2805.84|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3997.64||||3997.64|1185.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3997.64||||3997.64|1233.09|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3997.64||||3997.64|2805.84|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3997.64||||3997.64|1185.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3997.64||||3997.64|1185.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3997.64||||3997.64|2758.37|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3997.64||||3997.64|1185.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|3997.64||||3997.64|1399.17|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3997.64||||3997.64|1185.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3997.64||||3997.64|1185.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3997.64||||3997.64|1254.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3997.64||||3997.64|1233.09|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3997.64||||3997.64|1233.09|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3997.64||||3997.64|1254.3|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3997.64||||3997.64|1233.09|2805.84|49.19
165244|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 30 MG INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3997.64||||3997.64|2466.18|2805.84|49.19
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.67||||10.67|7.92|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.67||||10.67|3.16|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|10.67||||10.67|5.01|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.67||||10.67|0|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.67||||10.67|5.34|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.67||||10.67|6.72|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.67||||10.67|3.16|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|10.67||||10.67|5.87|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.67||||10.67|7.36|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.67||||10.67|5.34|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.67||||10.67|7.92|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.67||||10.67|3.16|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.67||||10.67|7.92|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.67||||10.67|3.16|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.67||||10.67|3.16|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.67||||10.67|7.36|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.67||||10.67|3.16|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|10.67||||10.67|3.73|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.67||||10.67|3.16|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.67||||10.67|3.16|7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.67||||10.67||7.92|3.16
1653|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.67||||10.67||7.92|3.16
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|40.28||||40.28|40.28|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40.28||||40.28|11.94|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|40.28||||40.28|18.93|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40.28||||40.28|0|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40.28||||40.28|20.14|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40.28||||40.28|25.38|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40.28||||40.28|11.94|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|40.28||||40.28|22.15|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|40.28||||40.28|27.79|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|40.28||||40.28|20.14|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40.28||||40.28|40.28|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40.28||||40.28|11.94|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40.28||||40.28|40.28|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40.28||||40.28|11.94|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|40.28||||40.28|11.94|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|40.28||||40.28|27.79|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40.28||||40.28|11.94|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|40.28||||40.28|14.1|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|40.28||||40.28|11.94|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40.28||||40.28|11.94|40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40.28||||40.28||40.28|11.94
1654|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40.28||||40.28||40.28|11.94
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.72||||11.72|11.72|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.72||||11.72|3.47|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|11.72||||11.72|5.51|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.72||||11.72|0|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.72||||11.72|5.86|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.72||||11.72|7.38|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.72||||11.72|3.47|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|11.72||||11.72|6.45|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.72||||11.72|8.09|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.72||||11.72|5.86|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.72||||11.72|11.72|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.72||||11.72|3.47|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.72||||11.72|11.72|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.72||||11.72|3.47|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.72||||11.72|3.47|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.72||||11.72|8.09|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.72||||11.72|3.47|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|11.72||||11.72|4.1|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.72||||11.72|3.47|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.72||||11.72|3.47|11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.72||||11.72||11.72|3.47
1656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.72||||11.72||11.72|3.47
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|26.4||||26.4|26.4|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.4||||26.4|7.83|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|26.4||||26.4|12.41|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.4||||26.4|0|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.4||||26.4|13.2|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.4||||26.4|16.63|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.4||||26.4|7.83|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|26.4||||26.4|14.52|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|26.4||||26.4|18.22|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|26.4||||26.4|13.2|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.4||||26.4|26.4|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.4||||26.4|7.83|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.4||||26.4|26.4|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.4||||26.4|7.83|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|26.4||||26.4|7.83|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|26.4||||26.4|18.22|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.4||||26.4|7.83|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|26.4||||26.4|9.24|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|26.4||||26.4|7.83|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.4||||26.4|7.83|26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.4||||26.4||26.4|7.83
1657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORPROMAZINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.4||||26.4||26.4|7.83
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.94||||5.94|2.62|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.94||||5.94|1.76|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.94||||5.94|2.79|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.94||||5.94|2.97|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.94||||5.94|2.97|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.94||||5.94|3.74|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.94||||5.94|1.76|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.94||||5.94|3.27|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.94||||5.94|4.1|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.94||||5.94|2.97|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.94||||5.94|2.62|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.94||||5.94|1.76|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.94||||5.94|2.62|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.94||||5.94|1.76|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.94||||5.94|1.76|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.94||||5.94|4.1|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.94||||5.94|1.76|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|Self-pay|Self-pay|5.94||||5.94|2.08|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.94||||5.94|1.76|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.94||||5.94|1.76|4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.94||||5.94||4.1|1.76
1661|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.94||||5.94||4.1|1.76
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.48||||2.48|1.09|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.48||||2.48|0.74|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.48||||2.48|1.17|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.48||||2.48|1.24|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.48||||2.48|1.24|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.48||||2.48|1.56|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.48||||2.48|0.74|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.48||||2.48|1.36|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.48||||2.48|1.71|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.48||||2.48|1.24|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.48||||2.48|1.09|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.48||||2.48|0.74|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.48||||2.48|1.09|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.48||||2.48|0.74|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.48||||2.48|0.74|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.48||||2.48|1.71|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.48||||2.48|0.74|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.48||||2.48|0.87|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.48||||2.48|0.74|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.48||||2.48|0.74|1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.48||||2.48||1.71|0.74
16632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.48||||2.48||1.71|0.74
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|2933.47||||2933.47|1131.12|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2933.47||||2933.47|869.77|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|2933.47||||2933.47|1378.73|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2933.47||||2933.47|0|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2933.47||||2933.47|1466.74|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2933.47||||2933.47|1848.09|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2933.47||||2933.47|869.77|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|2933.47||||2933.47|1466.74|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2933.47||||2933.47|2024.09|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2933.47||||2933.47|53.83|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2933.47||||2933.47|1131.12|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2933.47||||2933.47|869.77|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2933.47||||2933.47|1131.12|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2933.47||||2933.47|869.77|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|2933.47||||2933.47|869.77|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2933.47||||2933.47|2024.09|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2933.47||||2933.47|869.77|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|2933.47||||2933.47|1026.71|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2933.47||||2933.47|869.77|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2933.47||||2933.47|869.77|2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2933.47||||2933.47||2024.09|53.83
166758|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-DYYB 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2933.47||||2933.47||2024.09|53.83
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|737.71||||737.71|325.33|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|737.71||||737.71|218.73|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|737.71||||737.71|346.72|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|737.71||||737.71|0|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|737.71||||737.71|368.86|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|737.71||||737.71|464.76|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|737.71||||737.71|218.73|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|737.71||||737.71|368.86|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|737.71||||737.71|509.02|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|737.71||||737.71|7.75|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|737.71||||737.71|325.33|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|737.71||||737.71|218.73|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|737.71||||737.71|325.33|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|737.71||||737.71|218.73|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|737.71||||737.71|218.73|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|737.71||||737.71|509.02|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|737.71||||737.71|218.73|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|737.71||||737.71|258.2|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|737.71||||737.71|218.73|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|737.71||||737.71|218.73|509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|737.71||||737.71||509.02|7.75
166759|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLENE BLUE (ANTIDOTE) 5 MG/ML (0.5 %) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|737.71||||737.71||509.02|7.75
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|12.87||||12.87|6.67|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.87||||12.87||8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|12.87||||12.87|7.46|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.87||||12.87|3.82|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.87||||12.87||8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.87||||12.87||8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|12.87||||12.87|6.05|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.87||||12.87|0|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.87||||12.87|6.44|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.87||||12.87|8.11|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.87||||12.87|3.82|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.87||||12.87||8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|12.87||||12.87|7.08|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.87||||12.87|8.88|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.87||||12.87|3.43|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.87||||12.87||8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.87||||12.87|7.46|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.87||||12.87|3.82|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.87||||12.87||8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.87||||12.87|7.46|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.87||||12.87|3.82|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.87||||12.87|3.82|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.87||||12.87|8.88|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.87||||12.87|3.82|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|Self-pay|Self-pay|12.87||||12.87|4.5|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.87||||12.87|3.82|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.87||||12.87|3.82|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.87||||12.87|6.67|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.87||||12.87||8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.87||||12.87||8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.87||||12.87|6.67|8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.87||||12.87||8.88|3.43
167316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE (PF) 0.5 MG/0.5 ML INJECTION SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.87||||12.87||8.88|3.43
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|5278||||5278|2639|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5278||||5278|1741.08|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|5278||||5278|4084.32|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5278||||5278|1564.93|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5278||||5278|1723.84|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5278||||5278|1723.84|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|5278||||5278|2480.66|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5278||||5278|0|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5278||||5278|2639|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5278||||5278|3325.14|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5278||||5278|1564.93|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5278||||5278|1723.84|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|5278||||5278|2639|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5278||||5278|3641.82|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5278||||5278|106.66|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5278||||5278|1723.84|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5278||||5278|4084.32|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5278||||5278|1564.93|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5278||||5278|1723.84|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5278||||5278|4084.32|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5278||||5278|1564.93|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5278||||5278|1564.93|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5278||||5278|3641.82|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5278||||5278|1564.93|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|5278||||5278|1847.3|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5278||||5278|1564.93|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5278||||5278|1564.93|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5278||||5278|2639|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5278||||5278|1723.84|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5278||||5278|1723.84|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5278||||5278|2639|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5278||||5278|1723.84|4084.32|106.66
168234|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AVELUMAB 20 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5278||||5278|3447.68|4084.32|106.66
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.81||||0.81|0.36|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.81||||0.81|0.24|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.81||||0.81|0.38|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.81||||0.81|0.41|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.81||||0.81|0.41|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.81||||0.81|0.51|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.81||||0.81|0.24|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.81||||0.81|0.45|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.81||||0.81|0.56|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.81||||0.81|0.41|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.81||||0.81|0.36|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.81||||0.81|0.24|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.81||||0.81|0.36|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.81||||0.81|0.24|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.81||||0.81|0.24|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.81||||0.81|0.56|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.81||||0.81|0.24|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|Self-pay|Self-pay|0.81||||0.81|0.28|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.81||||0.81|0.24|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.81||||0.81|0.24|0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.81||||0.81||0.56|0.24
16830|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELATONIN 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.81||||0.81||0.56|0.24
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|AARP [1000]|AARP [100000]|4831.11||||4831.11|1684.05|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4831.11||||4831.11|1360.64|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|AETNA [1015]|AETNA [101529]|4831.11||||4831.11|3683.52|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4831.11||||4831.11|1432.42|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4831.11||||4831.11|1347.17|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4831.11||||4831.11|1347.17|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|BCBS [1155]|BCBS UTHCT [115568]|4831.11||||4831.11|2270.62|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4831.11||||4831.11|0|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4831.11||||4831.11|2415.56|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4831.11||||4831.11|3043.6|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4831.11||||4831.11|1432.42|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4831.11||||4831.11|1347.17|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|CIGNA [1260]|CIGNA GWH [126023]|4831.11||||4831.11|2415.56|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4831.11||||4831.11|3333.47|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4831.11||||4831.11|122.4|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4831.11||||4831.11|1347.17|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4831.11||||4831.11|3683.52|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4831.11||||4831.11|1432.42|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4831.11||||4831.11|1347.17|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4831.11||||4831.11|3683.52|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4831.11||||4831.11|1432.42|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4831.11||||4831.11|1432.42|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4831.11||||4831.11|3333.47|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4831.11||||4831.11|1432.42|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|Self-pay|Self-pay|4831.11||||4831.11|1690.89|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4831.11||||4831.11|1432.42|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4831.11||||4831.11|1432.42|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4831.11||||4831.11|1684.05|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4831.11||||4831.11|1347.17|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4831.11||||4831.11|1347.17|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4831.11||||4831.11|1684.05|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4831.11||||4831.11|1347.17|3683.52|122.4
168864|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB 150 MG INTRAVENOUS SOLUTION|7.15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4831.11||||4831.11|2694.33|3683.52|122.4
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|11531.94||||11531.94|5765.97|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11531.94||||11531.94|3881.58|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|11531.94||||11531.94|9141.6|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11531.94||||11531.94|3419.22|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11531.94||||11531.94|3843.15|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11531.94||||11531.94|3843.15|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|11531.94||||11531.94|5420.01|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11531.94||||11531.94|0|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11531.94||||11531.94|5765.97|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11531.94||||11531.94|7265.12|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11531.94||||11531.94|3419.22|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11531.94||||11531.94|3843.15|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|11531.94||||11531.94|5765.97|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11531.94||||11531.94|7957.04|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11531.94||||11531.94|96.31|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11531.94||||11531.94|3843.15|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11531.94||||11531.94|9141.6|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11531.94||||11531.94|3419.22|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11531.94||||11531.94|3843.15|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11531.94||||11531.94|9141.6|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11531.94||||11531.94|3419.22|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11531.94||||11531.94|3419.22|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11531.94||||11531.94|7957.04|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11531.94||||11531.94|3419.22|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|11531.94||||11531.94|4036.18|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11531.94||||11531.94|3419.22|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11531.94||||11531.94|3419.22|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11531.94||||11531.94|5765.97|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11531.94||||11531.94|3843.15|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11531.94||||11531.94|3843.15|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11531.94||||11531.94|5765.97|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11531.94||||11531.94|3843.15|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11531.94||||11531.94|7686.3|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|AARP [1000]|AARP [100000]|2767.68||||2767.68|935.88|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2767.68||||2767.68|931.58|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|AETNA [1015]|AETNA [101529]|2767.68||||2767.68|2193.98|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2767.68||||2767.68|820.62|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2767.68||||2767.68|922.36|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2767.68||||2767.68|922.36|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|BCBS [1155]|BCBS UTHCT [115568]|2767.68||||2767.68|1300.81|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2767.68||||2767.68|0|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2767.68||||2767.68|1383.84|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2767.68||||2767.68|1743.64|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2767.68||||2767.68|820.62|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2767.68||||2767.68|922.36|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|CIGNA [1260]|CIGNA GWH [126023]|2767.68||||2767.68|1383.84|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2767.68||||2767.68|1909.7|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2767.68||||2767.68|96.31|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2767.68||||2767.68|922.36|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2767.68||||2767.68|2193.98|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2767.68||||2767.68|820.62|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2767.68||||2767.68|922.36|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2767.68||||2767.68|2193.98|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2767.68||||2767.68|820.62|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2767.68||||2767.68|820.62|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2767.68||||2767.68|1909.7|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2767.68||||2767.68|820.62|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|Self-pay|Self-pay|2767.68||||2767.68|968.69|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2767.68||||2767.68|820.62|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2767.68||||2767.68|820.62|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2767.68||||2767.68|935.88|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2767.68||||2767.68|922.36|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2767.68||||2767.68|922.36|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2767.68||||2767.68|935.88|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2767.68||||2767.68|922.36|9141.6|96.31
169012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DURVALUMAB 50 MG/ML INTRAVENOUS SOLUTION|2.4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2767.68||||2767.68|1844.71|9141.6|96.31
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|2335.51||||2335.51|813.7|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2335.51||||2335.51|391.8|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|2335.51||||2335.51|1167.36|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2335.51||||2335.51|692.48|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2335.51||||2335.51|387.92|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2335.51||||2335.51|387.92|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|2335.51||||2335.51|1097.69|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2335.51||||2335.51|0|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2335.51||||2335.51|1167.76|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2335.51||||2335.51|1471.37|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2335.51||||2335.51|692.48|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2335.51||||2335.51|387.92|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|2335.51||||2335.51|1167.76|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2335.51||||2335.51|1611.5|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2335.51||||2335.51|52.61|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2335.51||||2335.51|387.92|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2335.51||||2335.51|1167.36|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2335.51||||2335.51|692.48|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2335.51||||2335.51|387.92|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2335.51||||2335.51|1167.36|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2335.51||||2335.51|692.48|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|2335.51||||2335.51|692.48|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2335.51||||2335.51|1611.5|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2335.51||||2335.51|692.48|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|2335.51||||2335.51|817.43|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2335.51||||2335.51|692.48|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2335.51||||2335.51|692.48|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2335.51||||2335.51|813.7|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2335.51||||2335.51|387.92|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2335.51||||2335.51|387.92|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2335.51||||2335.51|813.7|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2335.51||||2335.51|387.92|1611.5|52.61
169877|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB-ABDA 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2335.51||||2335.51|775.84|1611.5|52.61
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AARP [1000]|AARP [100000]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA [1015]|AETNA [101529]|3.97||||3.97|1.75|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.97||||3.97|1.18|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.97||||3.97|1.87|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.97||||3.97|1.99|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.97||||3.97|1.99|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.97||||3.97|2.5|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.97||||3.97|1.18|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.97||||3.97|2.18|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.97||||3.97|2.74|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.97||||3.97|1.99|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.97||||3.97|1.75|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.97||||3.97|1.18|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.97||||3.97|1.75|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.97||||3.97|1.18|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.97||||3.97|1.18|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.97||||3.97|2.74|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.97||||3.97|1.18|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|Self-pay|Self-pay|3.97||||3.97|1.39|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.97||||3.97|1.18|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.97||||3.97|1.18|2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.97||||3.97||2.74|1.18
17010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE ER 0.375 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.97||||3.97||2.74|1.18
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|AARP [1000]|AARP [100000]|328.91||||328.91|95.8|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|328.91||||328.91||226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|AETNA [1015]|AETNA [101529]|328.91||||328.91|130.22|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|328.91||||328.91|97.52|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|328.91||||328.91||226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|328.91||||328.91||226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|328.91||||328.91|154.59|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|328.91||||328.91|0|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|328.91||||328.91|164.46|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|328.91||||328.91|207.21|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|328.91||||328.91|97.52|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|328.91||||328.91||226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|328.91||||328.91|180.9|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|328.91||||328.91|226.95|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|328.91||||328.91|33.76|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|328.91||||328.91||226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|328.91||||328.91|130.22|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|328.91||||328.91|97.52|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|328.91||||328.91||226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|328.91||||328.91|130.22|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|328.91||||328.91|97.52|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|328.91||||328.91|97.52|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|328.91||||328.91|226.95|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|328.91||||328.91|97.52|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|Self-pay|Self-pay|328.91||||328.91|115.12|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|328.91||||328.91|97.52|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|328.91||||328.91|97.52|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|328.91||||328.91|95.8|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|328.91||||328.91||226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|328.91||||328.91||226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|328.91||||328.91|95.8|226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|328.91||||328.91||226.95|33.76
17012|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BLEOMYCIN 30 UNIT SOLUTION FOR INJECTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|328.91||||328.91||226.95|33.76
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AARP [1000]|AARP [100000]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.11||||2.11|0.93|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.11||||2.11|0.63|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.11||||2.11|0.99|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.11||||2.11|1.06|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.11||||2.11|1.06|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.11||||2.11|1.33|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.11||||2.11|0.63|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.11||||2.11|1.16|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.11||||2.11|1.46|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.11||||2.11|1.06|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.11||||2.11|0.93|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.11||||2.11|0.63|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.11||||2.11|0.93|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.11||||2.11|0.63|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.11||||2.11|0.63|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.11||||2.11|1.46|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.11||||2.11|0.63|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|Self-pay|Self-pay|2.11||||2.11|0.74|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.11||||2.11|0.63|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.11||||2.11|0.63|1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.11||||2.11||1.46|0.63
17023|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.11||||2.11||1.46|0.63
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AARP [1000]|AARP [100000]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AETNA [1015]|AETNA [101529]|132180||||132180|58291.38|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132180||||132180|39191.37|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS [1155]|BCBS UTHCT [115568]|132180||||132180|62124.6|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132180||||132180|0|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132180||||132180|66090|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132180||||132180|83273.4|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132180||||132180|39191.37|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|CIGNA [1260]|CIGNA GWH [126023]|132180||||132180|72699|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|132180||||132180|91204.2|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|132180||||132180|66090|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132180||||132180|58291.38|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132180||||132180|39191.37|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132180||||132180|58291.38|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132180||||132180|39191.37|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|132180||||132180|39191.37|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|132180||||132180|91204.2|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132180||||132180|39191.37|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|Self-pay|Self-pay|132180||||132180|46263|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|132180||||132180|39191.37|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132180||||132180|39191.37|91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132180||||132180||91204.2|39191.37
170401|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|FLUCICLOVINE F18 10 MCI (370 MBQ) INTRAVENOUS SOLUTION|10 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132180||||132180||91204.2|39191.37
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|171.87||||171.87|88.85|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|171.87||||171.87|46.56|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|171.87||||171.87|50.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|171.87||||171.87|80.78|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|171.87||||171.87|0|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|171.87||||171.87|85.94|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|171.87||||171.87|108.28|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|171.87||||171.87|50.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|171.87||||171.87|94.53|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|171.87||||171.87|118.59|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|171.87||||171.87|4.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|171.87||||171.87|46.56|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|171.87||||171.87|50.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|171.87||||171.87|46.56|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|171.87||||171.87|50.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|171.87||||171.87|50.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|171.87||||171.87|118.59|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|171.87||||171.87|50.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|171.87||||171.87|60.15|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|171.87||||171.87|50.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|171.87||||171.87|50.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|171.87||||171.87|88.85|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|171.87||||171.87|88.85|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|171.87||||171.87||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|327.36||||327.36|177.7|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|327.36||||327.36||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|327.36||||327.36|93.12|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|327.36||||327.36|97.06|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|327.36||||327.36||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|327.36||||327.36||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|327.36||||327.36|153.86|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|327.36||||327.36|0|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|327.36||||327.36|163.68|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|327.36||||327.36|206.24|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|327.36||||327.36|97.06|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|327.36||||327.36||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|327.36||||327.36|180.05|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|327.36||||327.36|225.88|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|327.36||||327.36|4.96|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|327.36||||327.36||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|327.36||||327.36|93.12|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|327.36||||327.36|97.06|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|327.36||||327.36||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|327.36||||327.36|93.12|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|327.36||||327.36|97.06|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|327.36||||327.36|97.06|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|327.36||||327.36|225.88|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|327.36||||327.36|97.06|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|327.36||||327.36|114.58|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|327.36||||327.36|97.06|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|327.36||||327.36|97.06|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|327.36||||327.36|177.7|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|327.36||||327.36||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|327.36||||327.36||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|327.36||||327.36|177.7|225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|327.36||||327.36||225.88|4.96
171005|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|327.36||||327.36||225.88|4.96
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|AARP [1000]|AARP [100000]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|AETNA [1015]|AETNA [101529]|22.9||||22.9|10.1|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.9||||22.9|6.79|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|22.9||||22.9|10.76|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.9||||22.9|11.45|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.9||||22.9|11.45|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.9||||22.9|14.43|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.9||||22.9|6.79|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|22.9||||22.9|12.6|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|22.9||||22.9|15.8|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22.9||||22.9|11.45|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.9||||22.9|10.1|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.9||||22.9|6.79|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.9||||22.9|10.1|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.9||||22.9|6.79|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|22.9||||22.9|6.79|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|22.9||||22.9|15.8|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.9||||22.9|6.79|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|Self-pay|Self-pay|22.9||||22.9|8.01|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22.9||||22.9|6.79|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.9||||22.9|6.79|15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.9||||22.9||15.8|6.79
171367|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 20,000-63,000-84,000 UNIT CAPSULE, DELAYED REL|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.9||||22.9||15.8|6.79
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AARP [1000]|AARP [100000]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AETNA [1015]|AETNA [101529]|45.18||||45.18|19.92|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45.18||||45.18|13.4|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|45.18||||45.18|21.23|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45.18||||45.18|22.59|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45.18||||45.18|22.59|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45.18||||45.18|28.46|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45.18||||45.18|13.4|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|45.18||||45.18|24.85|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|45.18||||45.18|31.17|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|45.18||||45.18|22.59|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45.18||||45.18|19.92|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45.18||||45.18|13.4|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45.18||||45.18|19.92|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45.18||||45.18|13.4|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|45.18||||45.18|13.4|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|45.18||||45.18|31.17|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45.18||||45.18|13.4|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|Self-pay|Self-pay|45.18||||45.18|15.81|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|45.18||||45.18|13.4|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45.18||||45.18|13.4|31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45.18||||45.18||31.17|13.4
171372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 40,000-126,000-168,000 UNIT CAPSULE, DELAY REL|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45.18||||45.18||31.17|13.4
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|AARP [1000]|AARP [100000]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|AETNA [1015]|AETNA [101529]|4969.24||||4969.24|2030.28|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4969.24||||4969.24|1473.38|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BCBS UTHCT [115568]|4969.24||||4969.24|2335.54|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4969.24||||4969.24|0|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4969.24||||4969.24|2484.62|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4969.24||||4969.24|3130.62|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4969.24||||4969.24|1473.38|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|CIGNA [1260]|CIGNA GWH [126023]|4969.24||||4969.24|2484.62|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|4969.24||||4969.24|3428.78|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4969.24||||4969.24|26.38|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4969.24||||4969.24|2030.28|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4969.24||||4969.24|1473.38|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4969.24||||4969.24|2030.28|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4969.24||||4969.24|1473.38|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|4969.24||||4969.24|1473.38|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|4969.24||||4969.24|3428.78|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4969.24||||4969.24|1473.38|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|Self-pay|Self-pay|4969.24||||4969.24|1739.23|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4969.24||||4969.24|1473.38|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4969.24||||4969.24|1473.38|3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4969.24||||4969.24||3428.78|26.38
171433|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BORTEZOMIB 3.5 MG INTRAVENOUS SOLUTION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4969.24||||4969.24||3428.78|26.38
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|AARP [1000]|AARP [100000]|21016||||21016|10000|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21016||||21016|6996.39|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|AETNA [1015]|AETNA [101529]|21016||||21016|16433.28|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21016||||21016|6231.24|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21016||||21016|6927.12|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21016||||21016|6927.12|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|BCBS [1155]|BCBS UTHCT [115568]|21016||||21016|9877.52|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21016||||21016|0|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21016||||21016|10508|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21016||||21016|13240.08|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21016||||21016|6231.24|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21016||||21016|6927.12|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|CIGNA [1260]|CIGNA GWH [126023]|21016||||21016|10508|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21016||||21016|14501.04|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21016||||21016|35.68|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21016||||21016|6927.12|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21016||||21016|16433.28|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21016||||21016|6231.24|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21016||||21016|6927.12|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21016||||21016|16433.28|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21016||||21016|6231.24|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21016||||21016|6231.24|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21016||||21016|14501.04|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21016||||21016|6231.24|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|Self-pay|Self-pay|21016||||21016|7355.6|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21016||||21016|6231.24|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21016||||21016|6231.24|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21016||||21016|10000|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21016||||21016|6927.12|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21016||||21016|6927.12|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21016||||21016|10000|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21016||||21016|6927.12|16433.28|35.68
171488|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NIVOLUMAB 240 MG/24 ML INTRAVENOUS SOLUTION|24 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21016||||21016|13854.24|16433.28|35.68
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|AARP [1000]|AARP [100000]|155280||||155280|77640|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|155280||||155280|55414.26|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|AETNA [1015]|AETNA [101529]|155280||||155280|115891.2|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|155280||||155280|46040.52|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|155280||||155280|54865.6|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|155280||||155280|54865.6|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|BCBS [1155]|BCBS UTHCT [115568]|155280||||155280|72981.6|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|155280||||155280|0|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|155280||||155280|77640|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|155280||||155280|97826.4|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|155280||||155280|46040.52|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|155280||||155280|54865.6|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|CIGNA [1260]|CIGNA GWH [126023]|155280||||155280|85404|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|155280||||155280|107143.2|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|155280||||155280|333.24|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|155280||||155280|54865.6|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|155280||||155280|115891.2|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|155280||||155280|46040.52|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|155280||||155280|54865.6|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|155280||||155280|115891.2|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|155280||||155280|46040.52|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|155280||||155280|46040.52|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|155280||||155280|107143.2|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|155280||||155280|46040.52|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|Self-pay|Self-pay|155280||||155280|54348|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|155280||||155280|46040.52|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|155280||||155280|46040.52|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|155280||||155280|77640|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|155280||||155280|54865.6|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|155280||||155280|54865.6|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|155280||||155280|77640|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|155280||||155280|54865.6|115891.2|333.24
171574|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|LUTETIUM LU 177 DOTATATE 10 MCI/ML (370 MBQ/ML) INTRAVENOUS SOLUTION|200 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|155280||||155280|109731.2|115891.2|333.24
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AARP [1000]|AARP [100000]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AETNA [1015]|AETNA [101529]|11.81||||11.81|5.21|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.81||||11.81|3.5|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS [1155]|BCBS UTHCT [115568]|11.81||||11.81|5.55|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.81||||11.81|5.91|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.81||||11.81|5.91|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.81||||11.81|7.44|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.81||||11.81|3.5|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|CIGNA [1260]|CIGNA GWH [126023]|11.81||||11.81|6.5|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|11.81||||11.81|8.15|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.81||||11.81|5.91|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.81||||11.81|5.21|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.81||||11.81|3.5|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.81||||11.81|5.21|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.81||||11.81|3.5|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.81||||11.81|3.5|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|11.81||||11.81|8.15|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.81||||11.81|3.5|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|Self-pay|Self-pay|11.81||||11.81|4.13|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.81||||11.81|3.5|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.81||||11.81|3.5|8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.81||||11.81||8.15|3.5
171617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 5,000-17,000-24,000 UNIT CAPSULE, DELAYED REL|2 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.81||||11.81||8.15|3.5
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|AARP [1000]|AARP [100000]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA [1015]|AETNA [101529]|28.33||||28.33|12.49|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.33||||28.33|8.4|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|28.33||||28.33|13.32|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.33||||28.33|14.17|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.33||||28.33|14.17|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.33||||28.33|17.85|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.33||||28.33|8.4|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|28.33||||28.33|15.58|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|28.33||||28.33|19.55|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|28.33||||28.33|14.17|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.33||||28.33|12.49|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.33||||28.33|8.4|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.33||||28.33|12.49|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.33||||28.33|8.4|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|28.33||||28.33|8.4|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|28.33||||28.33|19.55|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.33||||28.33|8.4|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|Self-pay|Self-pay|28.33||||28.33|9.92|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|28.33||||28.33|8.4|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.33||||28.33|8.4|19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.33||||28.33||19.55|8.4
171618|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 25,000-79,000-105,000 UNIT CAPSULE,DELAYED REL|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.33||||28.33||19.55|8.4
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|23.77||||23.77|15.02|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.77||||23.77|16|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|23.77||||23.77|23.77|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.77||||23.77|7.05|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.77||||23.77|15.84|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.77||||23.77|15.84|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|23.77||||23.77|11.17|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.77||||23.77|0|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.77||||23.77|11.89|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.77||||23.77|14.98|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.77||||23.77|7.05|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.77||||23.77|15.84|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|23.77||||23.77|13.07|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23.77||||23.77|16.4|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.77||||23.77|18.81|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.77||||23.77|15.84|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.77||||23.77|23.77|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.77||||23.77|7.05|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.77||||23.77|15.84|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.77||||23.77|23.77|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.77||||23.77|7.05|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.77||||23.77|7.05|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23.77||||23.77|16.4|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.77||||23.77|7.05|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|23.77||||23.77|8.32|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.77||||23.77|7.05|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.77||||23.77|7.05|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.77||||23.77|15.02|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.77||||23.77|15.84|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.77||||23.77|15.84|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.77||||23.77|15.02|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.77||||23.77|15.84|31.68|7.05
172332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON DEXTRAN 50 MG/ML INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.77||||23.77|31.68|31.68|7.05
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|AARP [1000]|AARP [100000]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA [1015]|AETNA [101529]|16.86||||16.86|7.44|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.86||||16.86|5|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|16.86||||16.86|7.92|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.86||||16.86|8.43|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.86||||16.86|8.43|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.86||||16.86|10.62|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.86||||16.86|5|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|16.86||||16.86|9.27|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|16.86||||16.86|11.63|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.86||||16.86|8.43|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.86||||16.86|7.44|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.86||||16.86|5|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.86||||16.86|7.44|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.86||||16.86|5|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.86||||16.86|5|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|16.86||||16.86|11.63|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.86||||16.86|5|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|Self-pay|Self-pay|16.86||||16.86|5.9|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.86||||16.86|5|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.86||||16.86|5|11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.86||||16.86||11.63|5
172641|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 15,000-47,000-63,000 UNIT CAPSULE,DELAYED REL|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.86||||16.86||11.63|5
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|AARP [1000]|AARP [100000]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|AETNA [1015]|AETNA [101529]|434||||434|116.16|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|434||||434|128.68|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|BCBS [1155]|BCBS UTHCT [115568]|434||||434|203.98|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|434||||434|0|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|434||||434|217|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|434||||434|273.42|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|434||||434|128.68|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|CIGNA [1260]|CIGNA GWH [126023]|434||||434|238.7|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|434||||434|299.46|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|434||||434|1.4|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|434||||434|116.16|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|434||||434|128.68|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|434||||434|116.16|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|434||||434|128.68|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|434||||434|128.68|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|434||||434|299.46|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|434||||434|128.68|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|Self-pay|Self-pay|434||||434|151.9|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|434||||434|128.68|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|434||||434|128.68|299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|434||||434||299.46|1.4
17285|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOPOTECAN 4 MG INTRAVENOUS SOLUTION|4 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|434||||434||299.46|1.4
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|245.77||||245.77|108.38|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|245.77||||245.77|72.87|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|245.77||||245.77|115.51|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|245.77||||245.77|122.89|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|245.77||||245.77|122.89|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|245.77||||245.77|154.84|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|245.77||||245.77|72.87|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|245.77||||245.77|135.17|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|245.77||||245.77|169.58|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|245.77||||245.77|122.89|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|245.77||||245.77|108.38|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|245.77||||245.77|72.87|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|245.77||||245.77|108.38|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|245.77||||245.77|72.87|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|245.77||||245.77|72.87|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|245.77||||245.77|169.58|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|245.77||||245.77|72.87|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|Self-pay|Self-pay|245.77||||245.77|86.02|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|245.77||||245.77|72.87|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|245.77||||245.77|72.87|169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|245.77||||245.77||169.58|72.87
173001|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BARICITINIB 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|245.77||||245.77||169.58|72.87
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|341.93||||341.93|216|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|341.93||||341.93|101.38|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|341.93||||341.93|160.71|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|341.93||||341.93|0|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|341.93||||341.93|170.97|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|341.93||||341.93|215.42|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|341.93||||341.93|101.38|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|341.93||||341.93|188.06|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|341.93||||341.93|235.93|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|341.93||||341.93|1.08|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|341.93||||341.93|216|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|341.93||||341.93|101.38|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|341.93||||341.93|216|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|341.93||||341.93|101.38|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|341.93||||341.93|101.38|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|341.93||||341.93|235.93|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|341.93||||341.93|101.38|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|341.93||||341.93|119.68|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|341.93||||341.93|101.38|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|341.93||||341.93|101.38|235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|341.93||||341.93||235.93|1.08
173070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 10,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|341.93||||341.93||235.93|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|1367.72||||1367.72|864|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1367.72||||1367.72|405.53|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|1367.72||||1367.72|642.83|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1367.72||||1367.72|0|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1367.72||||1367.72|683.86|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1367.72||||1367.72|861.66|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1367.72||||1367.72|405.53|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|1367.72||||1367.72|683.86|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1367.72||||1367.72|943.73|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1367.72||||1367.72|1.08|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1367.72||||1367.72|864|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1367.72||||1367.72|405.53|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1367.72||||1367.72|864|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1367.72||||1367.72|405.53|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1367.72||||1367.72|405.53|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1367.72||||1367.72|943.73|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1367.72||||1367.72|405.53|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|1367.72||||1367.72|478.7|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1367.72||||1367.72|405.53|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1367.72||||1367.72|405.53|943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1367.72||||1367.72||943.73|1.08
173071|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA-EPBX 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1367.72||||1367.72||943.73|1.08
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|73.21||||73.21|32.29|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|73.21||||73.21|21.71|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BCBS UTHCT [115568]|73.21||||73.21|34.41|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|73.21||||73.21|36.61|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|73.21||||73.21|36.61|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|73.21||||73.21|46.12|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|73.21||||73.21|21.71|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA GWH [126023]|73.21||||73.21|40.27|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|73.21||||73.21|50.51|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|73.21||||73.21|36.61|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|73.21||||73.21|32.29|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|73.21||||73.21|21.71|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|73.21||||73.21|32.29|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|73.21||||73.21|21.71|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|PENDING SSI [1616]|PENDING SSI RCA [161601]|73.21||||73.21|21.71|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|73.21||||73.21|50.51|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|73.21||||73.21|21.71|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|73.21||||73.21|25.62|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|73.21||||73.21|21.71|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|73.21||||73.21|21.71|50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|73.21||||73.21||50.51|21.71
173090|ERX|0250 - PHARMACY-GENERAL|SODIUM ZIRCONIUM CYCLOSILICATE 10 GRAM ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|73.21||||73.21||50.51|21.71
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|1332.54||||1332.54|418.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1332.54||||1332.54|415.14|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|1332.54||||1332.54|935.28|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1332.54||||1332.54|395.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1332.54||||1332.54|411.03|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1332.54||||1332.54|411.03|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1332.54||||1332.54|626.29|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1332.54||||1332.54|0|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1332.54||||1332.54|666.27|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1332.54||||1332.54|839.5|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1332.54||||1332.54|395.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1332.54||||1332.54|411.03|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1332.54||||1332.54|666.27|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1332.54||||1332.54|919.45|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1332.54||||1332.54|49.19|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1332.54||||1332.54|411.03|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1332.54||||1332.54|935.28|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1332.54||||1332.54|395.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1332.54||||1332.54|411.03|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1332.54||||1332.54|935.28|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1332.54||||1332.54|395.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1332.54||||1332.54|395.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1332.54||||1332.54|919.45|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1332.54||||1332.54|395.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|1332.54||||1332.54|466.39|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1332.54||||1332.54|395.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1332.54||||1332.54|395.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1332.54||||1332.54|418.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1332.54||||1332.54|411.03|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1332.54||||1332.54|411.03|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1332.54||||1332.54|418.1|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1332.54||||1332.54|411.03|935.28|49.19
173688|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARFILZOMIB 10 MG INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1332.54||||1332.54|822.06|935.28|49.19
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AARP [1000]|AARP [100000]|1086.24||||1086.24|456|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1086.24||||1086.24|157.56|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AETNA [1015]|AETNA [101529]|1086.24||||1086.24|714.24|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1086.24||||1086.24|322.07|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1086.24||||1086.24|156|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1086.24||||1086.24|156|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BCBS UTHCT [115568]|1086.24||||1086.24|510.53|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1086.24||||1086.24|543.12|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1086.24||||1086.24|543.12|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1086.24||||1086.24|684.33|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1086.24||||1086.24|322.07|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1086.24||||1086.24|156|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|CIGNA [1260]|CIGNA GWH [126023]|1086.24||||1086.24|543.12|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1086.24||||1086.24|749.51|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1086.24||||1086.24|0.65|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1086.24||||1086.24|156|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1086.24||||1086.24|714.24|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1086.24||||1086.24|322.07|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1086.24||||1086.24|156|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1086.24||||1086.24|714.24|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1086.24||||1086.24|322.07|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1086.24||||1086.24|322.07|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1086.24||||1086.24|749.51|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1086.24||||1086.24|322.07|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|Self-pay|Self-pay|1086.24||||1086.24|380.18|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1086.24||||1086.24|322.07|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1086.24||||1086.24|322.07|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1086.24||||1086.24|456|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1086.24||||1086.24|156|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1086.24||||1086.24|156|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1086.24||||1086.24|456|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1086.24||||1086.24|156|749.51|0.65
173748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FILGRASTIM-AAFI 480 MCG/0.8 ML SUBCUTANEOUS SYRINGE|0.8 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1086.24||||1086.24|312|749.51|0.65
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|AARP [1000]|AARP [100000]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|AETNA [1015]|AETNA [101529]|3.1||||3.1|1.37|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|BCBS [1155]|BCBS UTHCT [115568]|3.1||||3.1|1.46|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.1||||3.1|1.55|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.1||||3.1|1.55|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.1||||3.1|1.95|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|CIGNA [1260]|CIGNA GWH [126023]|3.1||||3.1|1.71|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.1||||3.1|2.14|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.1||||3.1|1.55|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.1||||3.1|1.37|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.1||||3.1|1.37|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.1||||3.1|2.14|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|Self-pay|Self-pay|3.1||||3.1|1.08|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|0.25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|AARP [1000]|AARP [100000]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|3.1||||3.1|1.37|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|3.1||||3.1|1.46|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.1||||3.1|1.55|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.1||||3.1|1.55|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.1||||3.1|1.95|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|3.1||||3.1|1.71|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.1||||3.1|2.14|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.1||||3.1|1.55|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.1||||3.1|1.37|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.1||||3.1|1.37|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.1||||3.1|2.14|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|Self-pay|Self-pay|3.1||||3.1|1.08|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.1||||3.1|0.92|2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.1||||3.1||2.14|0.92
17377|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG/ML ORAL SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.1||||3.1||2.14|0.92
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AARP [1000]|AARP [100000]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AETNA [1015]|AETNA [101529]|44.95||||44.95|9.48|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.95||||44.95|13.33|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS [1155]|BCBS UTHCT [115568]|44.95||||44.95|21.13|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.95||||44.95|0|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.95||||44.95|22.48|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.95||||44.95|28.32|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.95||||44.95|13.33|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|CIGNA [1260]|CIGNA GWH [126023]|44.95||||44.95|24.72|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|44.95||||44.95|31.02|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|44.95||||44.95|0.95|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.95||||44.95|9.48|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.95||||44.95|13.33|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.95||||44.95|9.48|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.95||||44.95|13.33|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|44.95||||44.95|13.33|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|44.95||||44.95|31.02|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.95||||44.95|13.33|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|Self-pay|Self-pay|44.95||||44.95|15.73|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|44.95||||44.95|13.33|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.95||||44.95|13.33|31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.95||||44.95||31.02|0.95
17379|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 500 MG INTRAVENOUS SOLUTION|0.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.95||||44.95||31.02|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AARP [1000]|AARP [100000]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA [1015]|AETNA [101529]|90.79||||90.79|18.96|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90.79||||90.79|26.92|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BCBS UTHCT [115568]|90.79||||90.79|42.67|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90.79||||90.79|0|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90.79||||90.79|45.4|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90.79||||90.79|57.2|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90.79||||90.79|26.92|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA GWH [126023]|90.79||||90.79|49.93|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|90.79||||90.79|62.65|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|90.79||||90.79|0.95|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90.79||||90.79|18.96|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90.79||||90.79|26.92|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90.79||||90.79|18.96|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90.79||||90.79|26.92|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|90.79||||90.79|26.92|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|90.79||||90.79|62.65|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90.79||||90.79|26.92|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|Self-pay|Self-pay|90.79||||90.79|31.78|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|90.79||||90.79|26.92|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90.79||||90.79|26.92|62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90.79||||90.79||62.65|0.95
17380|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEROPENEM 1 GRAM INTRAVENOUS SOLUTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90.79||||90.79||62.65|0.95
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.37||||1.37|0.6|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.37||||1.37|0.41|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.37||||1.37|0.64|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.37||||1.37|0.69|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.37||||1.37|0.69|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.37||||1.37|0.86|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.37||||1.37|0.41|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.37||||1.37|0.75|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.37||||1.37|0.95|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.37||||1.37|0.69|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.37||||1.37|0.6|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.37||||1.37|0.41|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.37||||1.37|0.6|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.37||||1.37|0.41|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.37||||1.37|0.41|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.37||||1.37|0.95|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.37||||1.37|0.41|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.37||||1.37|0.48|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.37||||1.37|0.41|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.37||||1.37|0.41|0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.37||||1.37||0.95|0.41
1740|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLINDAMYCIN HCL 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.37||||1.37||0.95|0.41
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|851.57||||851.57|398.4|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|851.57||||851.57|252.49|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|851.57||||851.57|400.24|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|851.57||||851.57|0|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|851.57||||851.57|425.79|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|851.57||||851.57|536.49|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|851.57||||851.57|252.49|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|851.57||||851.57|425.79|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|851.57||||851.57|587.58|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|851.57||||851.57|425.79|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|851.57||||851.57|398.4|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|851.57||||851.57|252.49|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|851.57||||851.57|398.4|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|851.57||||851.57|252.49|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|851.57||||851.57|252.49|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|851.57||||851.57|587.58|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|851.57||||851.57|252.49|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|Self-pay|Self-pay|851.57||||851.57|298.05|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|851.57||||851.57|252.49|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|851.57||||851.57|252.49|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|851.57||||851.57||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|255.48||||255.48|119.52|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|255.48||||255.48|75.75|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS [1155]|BCBS UTHCT [115568]|255.48||||255.48|120.08|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|255.48||||255.48|0|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|255.48||||255.48|127.74|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|255.48||||255.48|160.95|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|255.48||||255.48|75.75|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA GWH [126023]|255.48||||255.48|140.51|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|255.48||||255.48|176.28|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|255.48||||255.48|127.74|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|255.48||||255.48|119.52|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|255.48||||255.48|75.75|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|255.48||||255.48|119.52|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|255.48||||255.48|75.75|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|255.48||||255.48|75.75|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|255.48||||255.48|176.28|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|255.48||||255.48|75.75|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|Self-pay|Self-pay|255.48||||255.48|89.42|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|255.48||||255.48|75.75|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|255.48||||255.48|75.75|587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|255.48||||255.48||587.58|75.75
17405|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|255.48||||255.48||587.58|75.75
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|1801.63||||1801.63|597|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1801.63||||1801.63|570.67|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|1801.63||||1801.63|1356.84|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1801.63||||1801.63|534.18|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1801.63||||1801.63|565.02|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1801.63||||1801.63|565.02|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|1801.63||||1801.63|846.77|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1801.63||||1801.63|0|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1801.63||||1801.63|900.82|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1801.63||||1801.63|1135.03|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1801.63||||1801.63|534.18|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1801.63||||1801.63|565.02|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|1801.63||||1801.63|900.82|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1801.63||||1801.63|1243.12|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1801.63||||1801.63|46.78|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1801.63||||1801.63|565.02|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1801.63||||1801.63|1356.84|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1801.63||||1801.63|534.18|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1801.63||||1801.63|565.02|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1801.63||||1801.63|1356.84|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1801.63||||1801.63|534.18|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1801.63||||1801.63|534.18|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1801.63||||1801.63|1243.12|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1801.63||||1801.63|534.18|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|Self-pay|Self-pay|1801.63||||1801.63|630.57|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1801.63||||1801.63|534.18|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1801.63||||1801.63|534.18|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1801.63||||1801.63|597|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1801.63||||1801.63|565.02|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1801.63||||1801.63|565.02|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1801.63||||1801.63|597|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1801.63||||1801.63|565.02|1356.84|46.78
174267|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 75 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1801.63||||1801.63|1130.04|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|1801.63||||1801.63|597|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1801.63||||1801.63|570.67|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|1801.63||||1801.63|1356.84|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1801.63||||1801.63|534.18|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1801.63||||1801.63|565.02|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1801.63||||1801.63|565.02|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|1801.63||||1801.63|846.77|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1801.63||||1801.63|0|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1801.63||||1801.63|900.82|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1801.63||||1801.63|1135.03|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1801.63||||1801.63|534.18|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1801.63||||1801.63|565.02|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|1801.63||||1801.63|900.82|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1801.63||||1801.63|1243.12|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1801.63||||1801.63|46.78|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1801.63||||1801.63|565.02|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1801.63||||1801.63|1356.84|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1801.63||||1801.63|534.18|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1801.63||||1801.63|565.02|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1801.63||||1801.63|1356.84|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1801.63||||1801.63|534.18|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1801.63||||1801.63|534.18|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1801.63||||1801.63|1243.12|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1801.63||||1801.63|534.18|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|Self-pay|Self-pay|1801.63||||1801.63|630.57|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1801.63||||1801.63|534.18|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1801.63||||1801.63|534.18|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1801.63||||1801.63|597|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1801.63||||1801.63|565.02|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1801.63||||1801.63|565.02|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1801.63||||1801.63|597|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1801.63||||1801.63|565.02|1356.84|46.78
174269|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG/ML SUBCUTANEOUS SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1801.63||||1801.63|1130.04|1356.84|46.78
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|AARP [1000]|AARP [100000]|29205.82||||29205.82|14602.91|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29205.82||||29205.82|9736.1|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|AETNA [1015]|AETNA [101529]|29205.82||||29205.82|23024.4|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29205.82||||29205.82|8659.53|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29205.82||||29205.82|9639.7|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29205.82||||29205.82|9639.7|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|BCBS [1155]|BCBS UTHCT [115568]|29205.82||||29205.82|13726.74|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29205.82||||29205.82|0|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29205.82||||29205.82|14602.91|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29205.82||||29205.82|18399.67|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29205.82||||29205.82|8659.53|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29205.82||||29205.82|9639.7|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|CIGNA [1260]|CIGNA GWH [126023]|29205.82||||29205.82|14602.91|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|29205.82||||29205.82|20152.02|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29205.82||||29205.82|34.25|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29205.82||||29205.82|9639.7|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29205.82||||29205.82|23024.4|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29205.82||||29205.82|8659.53|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29205.82||||29205.82|9639.7|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29205.82||||29205.82|23024.4|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29205.82||||29205.82|8659.53|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29205.82||||29205.82|8659.53|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|29205.82||||29205.82|20152.02|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29205.82||||29205.82|8659.53|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|Self-pay|Self-pay|29205.82||||29205.82|10222.04|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29205.82||||29205.82|8659.53|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29205.82||||29205.82|8659.53|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29205.82||||29205.82|14602.91|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29205.82||||29205.82|9639.7|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29205.82||||29205.82|9639.7|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29205.82||||29205.82|14602.91|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29205.82||||29205.82|9639.7|23024.4|34.25
174319|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEMIPLIMAB-RWLC 50 MG/ML INTRAVENOUS SOLUTION|7 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29205.82||||29205.82|19279.4|23024.4|34.25
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.28||||0.28|0.12|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.28||||0.28|0.08|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.28||||0.28|0.13|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.28||||0.28|0.14|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.28||||0.28|0.14|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.28||||0.28|0.18|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.28||||0.28|0.08|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.28||||0.28|0.15|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.28||||0.28|0.19|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.28||||0.28|0.14|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.28||||0.28|0.12|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.28||||0.28|0.08|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.28||||0.28|0.12|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.28||||0.28|0.08|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.28||||0.28|0.08|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.28||||0.28|0.19|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.28||||0.28|0.08|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|Self-pay|Self-pay|0.28||||0.28|0.1|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.28||||0.28|0.08|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.28||||0.28|0.08|0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.28||||0.28||0.19|0.08
17464|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.28||||0.28||0.19|0.08
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.49||||0.49|0.22|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.49||||0.49|0.15|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.49||||0.49|0.23|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.49||||0.49|0.25|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.49||||0.49|0.25|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.49||||0.49|0.31|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.49||||0.49|0.15|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.49||||0.49|0.27|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.49||||0.49|0.34|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.49||||0.49|0.25|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.49||||0.49|0.22|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.49||||0.49|0.15|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.49||||0.49|0.22|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.49||||0.49|0.15|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.49||||0.49|0.15|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.49||||0.49|0.34|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.49||||0.49|0.15|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|Self-pay|Self-pay|0.49||||0.49|0.17|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.49||||0.49|0.15|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.49||||0.49|0.15|0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.49||||0.49||0.34|0.15
17466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.49||||0.49||0.34|0.15
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.37||||11.37|5.01|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.37||||11.37|3.37|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|11.37||||11.37|5.34|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.37||||11.37|5.69|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.37||||11.37|5.69|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.37||||11.37|7.16|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.37||||11.37|3.37|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|11.37||||11.37|6.25|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.37||||11.37|7.85|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.37||||11.37|5.69|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.37||||11.37|5.01|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.37||||11.37|3.37|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.37||||11.37|5.01|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.37||||11.37|3.37|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.37||||11.37|3.37|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.37||||11.37|7.85|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.37||||11.37|3.37|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|11.37||||11.37|3.98|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.37||||11.37|3.37|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.37||||11.37|3.37|7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.37||||11.37||7.85|3.37
17482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.37||||11.37||7.85|3.37
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|AARP [1000]|AARP [100000]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|AETNA [1015]|AETNA [101529]|74.75||||74.75|19.94|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.75||||74.75|22.16|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|BCBS [1155]|BCBS UTHCT [115568]|74.75||||74.75|35.13|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.75||||74.75|0|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.75||||74.75|37.38|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.75||||74.75|47.09|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.75||||74.75|22.16|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|CIGNA [1260]|CIGNA GWH [126023]|74.75||||74.75|41.11|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|74.75||||74.75|51.58|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.75||||74.75|3.26|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.75||||74.75|19.94|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.75||||74.75|22.16|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.75||||74.75|19.94|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.75||||74.75|22.16|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.75||||74.75|22.16|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|74.75||||74.75|51.58|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.75||||74.75|22.16|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|Self-pay|Self-pay|74.75||||74.75|26.16|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.75||||74.75|22.16|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.75||||74.75|22.16|51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.75||||74.75||51.58|3.26
174852|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.5 GRAM INTRAVENOUS SOLUTION|1.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.75||||74.75||51.58|3.26
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AARP [1000]|AARP [100000]|12942.5||||12942.5|6471.25|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12942.5||||12942.5|2695.19|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AETNA [1015]|AETNA [101529]|12942.5||||12942.5|8691.84|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12942.5||||12942.5|3837.45|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12942.5||||12942.5|2668.5|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12942.5||||12942.5|2668.5|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BCBS UTHCT [115568]|12942.5||||12942.5|6082.98|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12942.5||||12942.5|0|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12942.5||||12942.5|6471.25|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12942.5||||12942.5|8153.78|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12942.5||||12942.5|3837.45|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12942.5||||12942.5|2668.5|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|CIGNA [1260]|CIGNA GWH [126023]|12942.5||||12942.5|6471.25|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12942.5||||12942.5|8930.33|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12942.5||||12942.5|334.74|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12942.5||||12942.5|2668.5|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12942.5||||12942.5|8691.84|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12942.5||||12942.5|3837.45|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12942.5||||12942.5|2668.5|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12942.5||||12942.5|8691.84|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12942.5||||12942.5|3837.45|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12942.5||||12942.5|3837.45|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12942.5||||12942.5|8930.33|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12942.5||||12942.5|3837.45|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|Self-pay|Self-pay|12942.5||||12942.5|4529.87|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12942.5||||12942.5|3837.45|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12942.5||||12942.5|3837.45|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12942.5||||12942.5|6471.25|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12942.5||||12942.5|2668.5|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12942.5||||12942.5|2668.5|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12942.5||||12942.5|6471.25|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12942.5||||12942.5|2668.5|8930.33|334.74
174869|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEGFILGRASTIM-CBQV 6 MG/0.6 ML SUBCUTANEOUS SYRINGE|0.6 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12942.5||||12942.5|5337|8930.33|334.74
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|2621.21||||2621.21|1155.95|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2621.21||||2621.21|777.19|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|2621.21||||2621.21|1231.97|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2621.21||||2621.21|0|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2621.21||||2621.21|1310.61|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2621.21||||2621.21|1651.36|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2621.21||||2621.21|777.19|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|2621.21||||2621.21|1310.61|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2621.21||||2621.21|1808.63|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2621.21||||2621.21|85.63|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2621.21||||2621.21|1155.95|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2621.21||||2621.21|777.19|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2621.21||||2621.21|1155.95|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2621.21||||2621.21|777.19|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2621.21||||2621.21|777.19|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2621.21||||2621.21|1808.63|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2621.21||||2621.21|777.19|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|2621.21||||2621.21|917.42|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2621.21||||2621.21|777.19|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2621.21||||2621.21|777.19|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2621.21||||2621.21||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|13106.03||||13106.03|5779.76|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13106.03||||13106.03|3885.94|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|13106.03||||13106.03|6159.83|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13106.03||||13106.03|0|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13106.03||||13106.03|6553.02|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13106.03||||13106.03|8256.8|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13106.03||||13106.03|3885.94|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|13106.03||||13106.03|6553.02|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13106.03||||13106.03|9043.16|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13106.03||||13106.03|85.63|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13106.03||||13106.03|5779.76|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13106.03||||13106.03|3885.94|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13106.03||||13106.03|5779.76|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13106.03||||13106.03|3885.94|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13106.03||||13106.03|3885.94|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13106.03||||13106.03|9043.16|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13106.03||||13106.03|3885.94|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|13106.03||||13106.03|4587.11|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13106.03||||13106.03|3885.94|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13106.03||||13106.03|3885.94|9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13106.03||||13106.03||9043.16|85.63
175100|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RITUXIMAB-ABBS 10 MG/ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13106.03||||13106.03||9043.16|85.63
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|AARP [1000]|AARP [100000]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|AETNA [1015]|AETNA [101529]|62.31||||62.31|19.94|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62.31||||62.31|18.47|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|BCBS [1155]|BCBS UTHCT [115568]|62.31||||62.31|29.29|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|62.31||||62.31|0|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62.31||||62.31|31.16|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|62.31||||62.31|39.26|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|62.31||||62.31|18.47|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|CIGNA [1260]|CIGNA GWH [126023]|62.31||||62.31|34.27|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|62.31||||62.31|42.99|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|62.31||||62.31|3.26|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62.31||||62.31|19.94|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62.31||||62.31|18.47|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62.31||||62.31|19.94|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|62.31||||62.31|18.47|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|62.31||||62.31|18.47|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|62.31||||62.31|42.99|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62.31||||62.31|18.47|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|Self-pay|Self-pay|62.31||||62.31|21.81|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|62.31||||62.31|18.47|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|62.31||||62.31|18.47|42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62.31||||62.31||42.99|3.26
175161|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1.25 GRAM INTRAVENOUS SOLUTION|1,250 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|62.31||||62.31||42.99|3.26
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|AARP [1000]|AARP [100000]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|61.23||||61.23|50.28|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|61.23||||61.23|18.15|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|61.23||||61.23|28.78|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|61.23||||61.23|0|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|61.23||||61.23|30.62|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|61.23||||61.23|38.57|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|61.23||||61.23|18.15|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|61.23||||61.23|33.68|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|61.23||||61.23|42.25|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|61.23||||61.23|4.81|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|61.23||||61.23|50.28|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|61.23||||61.23|18.15|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|61.23||||61.23|50.28|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|61.23||||61.23|18.15|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|61.23||||61.23|18.15|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|61.23||||61.23|42.25|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|61.23||||61.23|18.15|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|Self-pay|Self-pay|61.23||||61.23|21.43|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|61.23||||61.23|18.15|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|61.23||||61.23|18.15|50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|61.23||||61.23||50.28|4.81
175171|ERX|0250 - PHARMACY-GENERAL|CALCIUM GLUCONATE 1 GRAM/50 ML IN SODIUM CHLORIDE, ISO-OSM IV SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|61.23||||61.23||50.28|4.81
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.14||||0.14|0.06|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.14||||0.14|0.04|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.14||||0.14|0.07|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.14||||0.14|0.07|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.14||||0.14|0.07|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.14||||0.14|0.09|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.14||||0.14|0.04|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.14||||0.14|0.08|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.14||||0.14|0.1|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.14||||0.14|0.07|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.14||||0.14|0.06|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.14||||0.14|0.04|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.14||||0.14|0.06|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.14||||0.14|0.04|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.14||||0.14|0.04|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.14||||0.14|0.1|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.14||||0.14|0.04|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|Self-pay|Self-pay|0.14||||0.14|0.05|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.14||||0.14|0.04|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.14||||0.14|0.04|0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.14||||0.14||0.1|0.04
1755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE HCL 0.1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.14||||0.14||0.1|0.04
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|AARP [1000]|AARP [100000]|20549.56||||20549.56|10274.78|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20549.56||||20549.56|6765.91|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|AETNA [1015]|AETNA [101529]|20549.56||||20549.56|15823.58|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20549.56||||20549.56|6092.94|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20549.56||||20549.56|6698.92|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20549.56||||20549.56|6698.92|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS [1155]|BCBS UTHCT [115568]|20549.56||||20549.56|9658.29|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20549.56||||20549.56|0|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20549.56||||20549.56|10274.78|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20549.56||||20549.56|12946.22|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20549.56||||20549.56|6092.94|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20549.56||||20549.56|6698.92|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|CIGNA [1260]|CIGNA GWH [126023]|20549.56||||20549.56|10274.78|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|20549.56||||20549.56|14179.2|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20549.56||||20549.56|97.73|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20549.56||||20549.56|6698.92|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20549.56||||20549.56|15823.58|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20549.56||||20549.56|6092.94|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20549.56||||20549.56|6698.92|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20549.56||||20549.56|15823.58|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20549.56||||20549.56|6092.94|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|20549.56||||20549.56|6092.94|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|20549.56||||20549.56|14179.2|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20549.56||||20549.56|6092.94|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|Self-pay|Self-pay|20549.56||||20549.56|7192.35|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20549.56||||20549.56|6092.94|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20549.56||||20549.56|6092.94|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20549.56||||20549.56|10274.78|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20549.56||||20549.56|6698.92|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20549.56||||20549.56|6698.92|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20549.56||||20549.56|10274.78|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20549.56||||20549.56|6698.92|15823.58|97.73
175622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATEZOLIZUMAB 840 MG/14 ML (60 MG/ML) INTRAVENOUS SOLUTION|14 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20549.56||||20549.56|13397.83|15823.58|97.73
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|AARP [1000]|AARP [100000]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|AETNA [1015]|AETNA [101529]|6016.92||||6016.92|4582.92|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6016.92||||6016.92|1784.02|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|BCBS [1155]|BCBS UTHCT [115568]|6016.92||||6016.92|2827.95|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6016.92||||6016.92|0|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6016.92||||6016.92|3008.46|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6016.92||||6016.92|3790.66|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6016.92||||6016.92|1784.02|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|CIGNA [1260]|CIGNA GWH [126023]|6016.92||||6016.92|3008.46|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6016.92||||6016.92|4151.67|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6016.92||||6016.92|11.25|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6016.92||||6016.92|4582.92|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6016.92||||6016.92|1784.02|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6016.92||||6016.92|4582.92|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6016.92||||6016.92|1784.02|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6016.92||||6016.92|1784.02|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6016.92||||6016.92|4151.67|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6016.92||||6016.92|1784.02|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|Self-pay|Self-pay|6016.92||||6016.92|2105.92|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6016.92||||6016.92|1784.02|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6016.92||||6016.92|1784.02|4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6016.92||||6016.92||4582.92|11.25
175709|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMOSOZUMAB-AQQG 210 MG/2.34 ML(105 MG/1.17 ML X2)SUBCUTANEOUS SYRINGE|2.35 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6016.92||||6016.92||4582.92|11.25
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AARP [1000]|AARP [100000]|2162.97||||2162.97|627.9|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2162.97||||2162.97|450.03|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|2162.97||||2162.97|1498.08|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2162.97||||2162.97|641.32|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2162.97||||2162.97|445.57|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2162.97||||2162.97|445.57|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|2162.97||||2162.97|1016.6|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2162.97||||2162.97|0|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2162.97||||2162.97|1081.49|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2162.97||||2162.97|1362.67|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2162.97||||2162.97|641.32|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2162.97||||2162.97|445.57|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|2162.97||||2162.97|1081.49|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2162.97||||2162.97|1492.45|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2162.97||||2162.97|70.91|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2162.97||||2162.97|445.57|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2162.97||||2162.97|1498.08|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2162.97||||2162.97|641.32|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2162.97||||2162.97|445.57|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2162.97||||2162.97|1498.08|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2162.97||||2162.97|641.32|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2162.97||||2162.97|641.32|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2162.97||||2162.97|1492.45|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2162.97||||2162.97|641.32|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|Self-pay|Self-pay|2162.97||||2162.97|757.04|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2162.97||||2162.97|641.32|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2162.97||||2162.97|641.32|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2162.97||||2162.97|627.9|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2162.97||||2162.97|445.57|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2162.97||||2162.97|445.57|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2162.97||||2162.97|627.9|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2162.97||||2162.97|445.57|1498.08|70.91
176248|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BEVACIZUMAB-AWWB 25 MG/ML INTRAVENOUS SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2162.97||||2162.97|891.14|1498.08|70.91
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|11805.36||||11805.36|5902.68|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11805.36||||11805.36|2256.02|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|11805.36||||11805.36|5206.16|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11805.36||||11805.36|3500.29|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11805.36||||11805.36|2233.69|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11805.36||||11805.36|2233.69|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|11805.36||||11805.36|5548.52|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11805.36||||11805.36|0|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11805.36||||11805.36|5902.68|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11805.36||||11805.36|7437.38|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11805.36||||11805.36|3500.29|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11805.36||||11805.36|2233.69|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|11805.36||||11805.36|5902.68|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11805.36||||11805.36|8145.7|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11805.36||||11805.36|90.63|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11805.36||||11805.36|2233.69|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11805.36||||11805.36|5206.16|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11805.36||||11805.36|3500.29|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11805.36||||11805.36|2233.69|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11805.36||||11805.36|5206.16|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11805.36||||11805.36|3500.29|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11805.36||||11805.36|3500.29|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11805.36||||11805.36|8145.7|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11805.36||||11805.36|3500.29|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|11805.36||||11805.36|4131.88|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11805.36||||11805.36|3500.29|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11805.36||||11805.36|3500.29|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11805.36||||11805.36|5902.68|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11805.36||||11805.36|2233.69|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11805.36||||11805.36|2233.69|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11805.36||||11805.36|5902.68|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11805.36||||11805.36|2233.69|8145.7|90.63
176316|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRASTUZUMAB-ANNS 420 MG INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11805.36||||11805.36|4467.37|8145.7|90.63
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|AARP [1000]|AARP [100000]|7.44||||7.44|2.3|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.44||||7.44||5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|7.44||||7.44|2.88|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.44||||7.44|2.21|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.44||||7.44||5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.44||||7.44||5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|7.44||||7.44|3.5|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.44||||7.44|0|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.44||||7.44|3.72|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.44||||7.44|4.69|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.44||||7.44|2.21|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.44||||7.44||5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|7.44||||7.44|4.09|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.44||||7.44|5.13|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.44||||7.44|0.18|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.44||||7.44||5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.44||||7.44|2.88|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.44||||7.44|2.21|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.44||||7.44||5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.44||||7.44|2.88|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.44||||7.44|2.21|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.44||||7.44|2.21|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.44||||7.44|5.13|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.44||||7.44|2.21|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|Self-pay|Self-pay|7.44||||7.44|2.6|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.44||||7.44|2.21|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.44||||7.44|2.21|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.44||||7.44|2.3|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.44||||7.44||5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.44||||7.44||5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.44||||7.44|2.3|5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.44||||7.44||5.13|0.18
176692|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.44||||7.44||5.13|0.18
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|AARP [1000]|AARP [100000]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|108.5||||108.5|47.85|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.5||||108.5|32.17|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|108.5||||108.5|51|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.5||||108.5|54.25|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.5||||108.5|54.25|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.5||||108.5|68.36|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.5||||108.5|32.17|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|108.5||||108.5|59.68|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|108.5||||108.5|74.87|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|108.5||||108.5|54.25|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.5||||108.5|47.85|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.5||||108.5|32.17|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.5||||108.5|47.85|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.5||||108.5|32.17|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|108.5||||108.5|32.17|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|108.5||||108.5|74.87|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.5||||108.5|32.17|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|Self-pay|Self-pay|108.5||||108.5|37.97|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|108.5||||108.5|32.17|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.5||||108.5|32.17|74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.5||||108.5||74.87|32.17
176787|ERX|0250 - PHARMACY-GENERAL|INSULIN REGULAR 100 UNIT/100 ML (1 UNIT/ML) IN 0.9 % NACL IV SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.5||||108.5||74.87|32.17
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|10990.09||||10990.09|5495.05|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10990.09||||10990.09|3721.35|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|10990.09||||10990.09|4846.63|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10990.09||||10990.09|3258.56|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10990.09||||10990.09|3684.5|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10990.09||||10990.09|3684.5|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|10990.09||||10990.09|5165.34|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10990.09||||10990.09|0|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10990.09||||10990.09|5495.05|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10990.09||||10990.09|6923.76|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10990.09||||10990.09|3258.56|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10990.09||||10990.09|3684.5|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|10990.09||||10990.09|5495.05|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10990.09||||10990.09|7583.16|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10990.09||||10990.09|45.39|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10990.09||||10990.09|3684.5|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10990.09||||10990.09|4846.63|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10990.09||||10990.09|3258.56|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10990.09||||10990.09|3684.5|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10990.09||||10990.09|4846.63|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10990.09||||10990.09|3258.56|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10990.09||||10990.09|3258.56|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10990.09||||10990.09|7583.16|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10990.09||||10990.09|3258.56|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|Self-pay|Self-pay|10990.09||||10990.09|3846.53|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10990.09||||10990.09|3258.56|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10990.09||||10990.09|3258.56|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10990.09||||10990.09|5495.05|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10990.09||||10990.09|3684.5|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10990.09||||10990.09|3684.5|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10990.09||||10990.09|5495.05|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10990.09||||10990.09|3684.5|7583.16|45.39
177048|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 25 MG SUBCUTANEOUS SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10990.09||||10990.09|7369|7583.16|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|AARP [1000]|AARP [100000]|32970.24||||32970.24|16485.12|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32970.24||||32970.24|11164.04|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|AETNA [1015]|AETNA [101529]|32970.24||||32970.24|14539.88|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32970.24||||32970.24|9775.68|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32970.24||||32970.24|11053.5|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32970.24||||32970.24|11053.5|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|BCBS [1155]|BCBS UTHCT [115568]|32970.24||||32970.24|15496.01|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32970.24||||32970.24|0|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32970.24||||32970.24|16485.12|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32970.24||||32970.24|20771.25|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32970.24||||32970.24|9775.68|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32970.24||||32970.24|11053.5|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|CIGNA [1260]|CIGNA GWH [126023]|32970.24||||32970.24|16485.12|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|32970.24||||32970.24|22749.47|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|32970.24||||32970.24|45.39|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32970.24||||32970.24|11053.5|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32970.24||||32970.24|14539.88|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32970.24||||32970.24|9775.68|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32970.24||||32970.24|11053.5|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32970.24||||32970.24|14539.88|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32970.24||||32970.24|9775.68|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|32970.24||||32970.24|9775.68|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|32970.24||||32970.24|22749.47|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32970.24||||32970.24|9775.68|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|Self-pay|Self-pay|32970.24||||32970.24|11539.58|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|32970.24||||32970.24|9775.68|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32970.24||||32970.24|9775.68|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32970.24||||32970.24|16485.12|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|32970.24||||32970.24|11053.5|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32970.24||||32970.24|11053.5|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32970.24||||32970.24|16485.12|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32970.24||||32970.24|11053.5|22749.47|45.39
177050|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LUSPATERCEPT-AAMT 75 MG SUBCUTANEOUS SOLUTION|1.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32970.24||||32970.24|22107|22749.47|45.39
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|AARP [1000]|AARP [100000]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|AETNA [1015]|AETNA [101529]|576||||576|254.02|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|576||||576|170.78|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|BCBS [1155]|BCBS UTHCT [115568]|576||||576|270.72|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|576||||576|288|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|576||||576|288|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|576||||576|362.88|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|576||||576|170.78|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|CIGNA [1260]|CIGNA GWH [126023]|576||||576|316.8|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|576||||576|397.44|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|576||||576|288|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|576||||576|254.02|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|576||||576|170.78|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|576||||576|254.02|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|576||||576|170.78|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|576||||576|170.78|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|576||||576|397.44|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|576||||576|170.78|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|Self-pay|Self-pay|576||||576|201.6|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|576||||576|170.78|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|576||||576|170.78|397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|576||||576||397.44|170.78
177538|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO XE133 XENON GAS PER VIAL 20 MCI|20 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|576||||576||397.44|170.78
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|7331.5||||7331.5|3665.75|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7331.5||||7331.5|2437.74|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|7331.5||||7331.5|3233.19|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7331.5||||7331.5|2173.79|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7331.5||||7331.5|2413.6|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7331.5||||7331.5|2413.6|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|7331.5||||7331.5|3445.81|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7331.5||||7331.5|0|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7331.5||||7331.5|3665.75|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7331.5||||7331.5|4618.85|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7331.5||||7331.5|2173.79|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7331.5||||7331.5|2413.6|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|7331.5||||7331.5|3665.75|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7331.5||||7331.5|5058.74|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7331.5||||7331.5|34.95|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7331.5||||7331.5|2413.6|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7331.5||||7331.5|3233.19|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7331.5||||7331.5|2173.79|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7331.5||||7331.5|2413.6|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7331.5||||7331.5|3233.19|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7331.5||||7331.5|2173.79|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7331.5||||7331.5|2173.79|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7331.5||||7331.5|5058.74|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7331.5||||7331.5|2173.79|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|7331.5||||7331.5|2566.02|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7331.5||||7331.5|2173.79|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7331.5||||7331.5|2173.79|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7331.5||||7331.5|3665.75|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7331.5||||7331.5|2413.6|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7331.5||||7331.5|2413.6|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7331.5||||7331.5|3665.75|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7331.5||||7331.5|2413.6|5058.74|34.95
177875|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 20 MG INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7331.5||||7331.5|4827.2|5058.74|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|10997.25||||10997.25|5498.63|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10997.25||||10997.25|3656.6|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|10997.25||||10997.25|4849.79|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10997.25||||10997.25|3260.68|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10997.25||||10997.25|3620.4|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10997.25||||10997.25|3620.4|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BCBS UTHCT [115568]|10997.25||||10997.25|5168.71|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10997.25||||10997.25|0|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10997.25||||10997.25|5498.63|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10997.25||||10997.25|6928.27|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10997.25||||10997.25|3260.68|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10997.25||||10997.25|3620.4|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA GWH [126023]|10997.25||||10997.25|5498.63|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10997.25||||10997.25|7588.1|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10997.25||||10997.25|34.95|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10997.25||||10997.25|3620.4|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10997.25||||10997.25|4849.79|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10997.25||||10997.25|3260.68|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10997.25||||10997.25|3620.4|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10997.25||||10997.25|4849.79|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10997.25||||10997.25|3260.68|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10997.25||||10997.25|3260.68|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10997.25||||10997.25|7588.1|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10997.25||||10997.25|3260.68|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|Self-pay|Self-pay|10997.25||||10997.25|3849.04|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10997.25||||10997.25|3260.68|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10997.25||||10997.25|3260.68|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10997.25||||10997.25|5498.63|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10997.25||||10997.25|3620.4|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10997.25||||10997.25|3620.4|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10997.25||||10997.25|5498.63|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10997.25||||10997.25|3620.4|7588.1|34.95
177876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENFORTUMAB VEDOTIN-EJFV 30 MG INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10997.25||||10997.25|7240.8|7588.1|34.95
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|7332.65||||7332.65|3666.33|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7332.65||||7332.65|2450.97|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|7332.65||||7332.65|3233.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7332.65||||7332.65|2174.13|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7332.65||||7332.65|2426.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7332.65||||7332.65|2426.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|7332.65||||7332.65|3446.35|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7332.65||||7332.65|0|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7332.65||||7332.65|3666.33|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7332.65||||7332.65|4619.57|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7332.65||||7332.65|2174.13|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7332.65||||7332.65|2426.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|7332.65||||7332.65|3666.33|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7332.65||||7332.65|5059.53|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7332.65||||7332.65|30.16|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7332.65||||7332.65|2426.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7332.65||||7332.65|3233.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7332.65||||7332.65|2174.13|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7332.65||||7332.65|2426.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7332.65||||7332.65|3233.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7332.65||||7332.65|2174.13|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7332.65||||7332.65|2174.13|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7332.65||||7332.65|5059.53|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7332.65||||7332.65|2174.13|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|7332.65||||7332.65|2566.43|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7332.65||||7332.65|2174.13|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7332.65||||7332.65|2174.13|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7332.65||||7332.65|3666.33|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7332.65||||7332.65|2426.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7332.65||||7332.65|2426.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7332.65||||7332.65|3666.33|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7332.65||||7332.65|2426.7|5059.53|30.16
177881|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FAM-TRASTUZUMAB DERUXTECAN-NXKI 100 MG INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7332.65||||7332.65|4853.4|5059.53|30.16
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|AARP [1000]|AARP [100000]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|AETNA [1015]|AETNA [101529]|68.4||||68.4|30.16|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|68.4||||68.4|20.28|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|BCBS [1155]|BCBS UTHCT [115568]|68.4||||68.4|32.15|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|68.4||||68.4|34.2|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|68.4||||68.4|34.2|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|68.4||||68.4|43.09|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|68.4||||68.4|20.28|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|CIGNA [1260]|CIGNA GWH [126023]|68.4||||68.4|37.62|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|GROUP PENSION ADMIN [1450]|GPA [145000]|68.4||||68.4|47.2|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|68.4||||68.4|34.2|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|68.4||||68.4|30.16|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|68.4||||68.4|20.28|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|68.4||||68.4|30.16|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|68.4||||68.4|20.28|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|68.4||||68.4|20.28|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|PHCS [1780]|PHCS MULTIPLAN [178000]|68.4||||68.4|47.2|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|68.4||||68.4|20.28|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|Self-pay|Self-pay|68.4||||68.4|23.94|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|68.4||||68.4|20.28|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|68.4||||68.4|20.28|47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|68.4||||68.4||47.2|20.28
17837|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE HFA 90 MCG/ACTUATION AEROSOL INHALER|8 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|68.4||||68.4||47.2|20.28
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AARP [1000]|AARP [100000]|10585.03||||10585.03|5292.52|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10585.03||||10585.03|3413.7|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA [1015]|AETNA [101529]|10585.03||||10585.03|4668|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10585.03||||10585.03|3138.46|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10585.03||||10585.03|3379.9|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10585.03||||10585.03|3379.9|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BCBS UTHCT [115568]|10585.03||||10585.03|4974.96|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10585.03||||10585.03|0|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10585.03||||10585.03|5292.52|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10585.03||||10585.03|6668.57|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10585.03||||10585.03|3138.46|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10585.03||||10585.03|3379.9|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA [1260]|CIGNA GWH [126023]|10585.03||||10585.03|5292.52|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10585.03||||10585.03|7303.67|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10585.03||||10585.03|82.96|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10585.03||||10585.03|3379.9|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10585.03||||10585.03|4668|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10585.03||||10585.03|3138.46|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10585.03||||10585.03|3379.9|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10585.03||||10585.03|4668|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10585.03||||10585.03|3138.46|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10585.03||||10585.03|3138.46|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10585.03||||10585.03|7303.67|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10585.03||||10585.03|3138.46|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|Self-pay|Self-pay|10585.03||||10585.03|3704.76|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10585.03||||10585.03|3138.46|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10585.03||||10585.03|3138.46|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10585.03||||10585.03|5292.52|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10585.03||||10585.03|3379.9|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10585.03||||10585.03|3379.9|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10585.03||||10585.03|5292.52|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10585.03||||10585.03|3379.9|7303.67|82.96
178453|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ISATUXIMAB-IRFC 20 MG/ML INTRAVENOUS SOLUTION|25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10585.03||||10585.03|6759.8|7303.67|82.96
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|AARP [1000]|AARP [100000]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|AETNA [1015]|AETNA [101529]|6618.72||||6618.72|2918.86|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6618.72||||6618.72|1962.45|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|BCBS [1155]|BCBS UTHCT [115568]|6618.72||||6618.72|3110.8|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6618.72||||6618.72|0|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6618.72||||6618.72|3309.36|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6618.72||||6618.72|4169.79|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6618.72||||6618.72|1962.45|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|CIGNA [1260]|CIGNA GWH [126023]|6618.72||||6618.72|3309.36|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6618.72||||6618.72|4566.92|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6618.72||||6618.72|36.89|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6618.72||||6618.72|2918.86|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6618.72||||6618.72|1962.45|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6618.72||||6618.72|2918.86|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6618.72||||6618.72|1962.45|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6618.72||||6618.72|1962.45|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6618.72||||6618.72|4566.92|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6618.72||||6618.72|1962.45|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|Self-pay|Self-pay|6618.72||||6618.72|2316.55|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6618.72||||6618.72|1962.45|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6618.72||||6618.72|1962.45|4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6618.72||||6618.72||4566.92|36.89
178775|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SACITUZUMAB GOVITECAN-HZIY 180 MG INTRAVENOUS SOLUTION|18 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6618.72||||6618.72||4566.92|36.89
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|AARP [1000]|AARP [100000]|24606.41||||24606.41|12303.21|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24606.41||||24606.41|8198.82|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|AETNA [1015]|AETNA [101529]|24606.41||||24606.41|10851.43|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24606.41||||24606.41|7295.8|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24606.41||||24606.41|8117.64|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24606.41||||24606.41|8117.64|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|BCBS [1155]|BCBS UTHCT [115568]|24606.41||||24606.41|11565.01|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24606.41||||24606.41|0|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24606.41||||24606.41|12303.21|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24606.41||||24606.41|15502.04|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24606.41||||24606.41|7295.8|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24606.41||||24606.41|8117.64|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|CIGNA [1260]|CIGNA GWH [126023]|24606.41||||24606.41|12303.21|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24606.41||||24606.41|16978.42|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24606.41||||24606.41|54.81|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24606.41||||24606.41|8117.64|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24606.41||||24606.41|10851.43|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24606.41||||24606.41|7295.8|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24606.41||||24606.41|8117.64|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24606.41||||24606.41|10851.43|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24606.41||||24606.41|7295.8|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|24606.41||||24606.41|7295.8|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24606.41||||24606.41|16978.42|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24606.41||||24606.41|7295.8|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|Self-pay|Self-pay|24606.41||||24606.41|8612.24|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24606.41||||24606.41|7295.8|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24606.41||||24606.41|7295.8|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24606.41||||24606.41|12303.21|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24606.41||||24606.41|8117.64|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24606.41||||24606.41|8117.64|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24606.41||||24606.41|12303.21|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24606.41||||24606.41|8117.64|16978.42|54.81
178799|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DARATUMUMAB 1,800 MG-HYALURONIDASE-FIHJ 30,000 UNIT/15 ML SUBCUT SOLN|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24606.41||||24606.41|16235.28|16978.42|54.81
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|44.95||||44.95|19.82|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.95||||44.95|13.33|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|44.95||||44.95|21.13|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.95||||44.95|22.48|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.95||||44.95|22.48|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.95||||44.95|28.32|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.95||||44.95|13.33|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|44.95||||44.95|24.72|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|44.95||||44.95|31.02|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|44.95||||44.95|22.48|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.95||||44.95|19.82|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.95||||44.95|13.33|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.95||||44.95|19.82|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.95||||44.95|13.33|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|44.95||||44.95|13.33|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|44.95||||44.95|31.02|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.95||||44.95|13.33|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|Self-pay|Self-pay|44.95||||44.95|15.73|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|44.95||||44.95|13.33|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.95||||44.95|13.33|31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.95||||44.95||31.02|13.33
17881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.2 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.95||||44.95||31.02|13.33
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AARP [1000]|AARP [100000]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|650||||650|286.65|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|650||||650|192.73|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|650||||650|305.5|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|650||||650|325|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|650||||650|325|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|650||||650|409.5|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|650||||650|192.73|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|650||||650|357.5|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|650||||650|448.5|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|650||||650|325|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|650||||650|286.65|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|650||||650|192.73|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|650||||650|286.65|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|650||||650|192.73|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|650||||650|192.73|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|650||||650|448.5|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|650||||650|192.73|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|Self-pay|Self-pay|650||||650|227.5|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|650||||650|192.73|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|650||||650|192.73|448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|650||||650||448.5|192.73
179027|ERX|0250 - PHARMACY-GENERAL|REMDESIVIR 100 MG INTRAVENOUS POWDER FOR SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|650||||650||448.5|192.73
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.55||||1.55|0.68|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.55||||1.55|0.46|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.55||||1.55|0.73|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.55||||1.55|0.78|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.55||||1.55|0.78|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.55||||1.55|0.98|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.55||||1.55|0.46|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.55||||1.55|0.85|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.55||||1.55|1.07|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.55||||1.55|0.78|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.55||||1.55|0.68|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.55||||1.55|0.46|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.55||||1.55|0.68|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.55||||1.55|0.46|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.55||||1.55|0.46|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.55||||1.55|1.07|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.55||||1.55|0.46|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.55||||1.55|0.54|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.55||||1.55|0.46|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.55||||1.55|0.46|1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.55||||1.55||1.07|0.46
17936|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.55||||1.55||1.07|0.46
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.41||||2.41|1.06|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.41||||2.41|0.71|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.41||||2.41|1.13|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.41||||2.41|1.21|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.41||||2.41|1.21|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.41||||2.41|1.52|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.41||||2.41|0.71|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.41||||2.41|1.33|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.41||||2.41|1.66|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.41||||2.41|1.21|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.41||||2.41|1.06|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.41||||2.41|0.71|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.41||||2.41|1.06|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.41||||2.41|0.71|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.41||||2.41|0.71|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.41||||2.41|1.66|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.41||||2.41|0.71|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.41||||2.41|0.84|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.41||||2.41|0.71|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.41||||2.41|0.71|1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.41||||2.41||1.66|0.71
17937|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.41||||2.41||1.66|0.71
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.88||||0.88|0.39|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.88||||0.88|0.26|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.88||||0.88|0.41|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.88||||0.88|0.44|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.88||||0.88|0.44|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.88||||0.88|0.55|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.88||||0.88|0.26|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.88||||0.88|0.48|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.88||||0.88|0.61|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.88||||0.88|0.44|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.88||||0.88|0.39|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.88||||0.88|0.26|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.88||||0.88|0.39|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.88||||0.88|0.26|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.88||||0.88|0.26|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.88||||0.88|0.61|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.88||||0.88|0.26|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.88||||0.88|0.31|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.88||||0.88|0.26|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.88||||0.88|0.26|0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.88||||0.88||0.61|0.26
17938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 7.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.88||||0.88||0.61|0.26
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AARP [1000]|AARP [100000]|1135.38||||1135.38|373.1|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1135.38||||1135.38|147.22|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AETNA [1015]|AETNA [101529]|1135.38||||1135.38|414.84|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1135.38||||1135.38|336.64|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1135.38||||1135.38|145.77|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1135.38||||1135.38|145.77|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|1135.38||||1135.38|533.63|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1135.38||||1135.38|0|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1135.38||||1135.38|567.69|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1135.38||||1135.38|715.29|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1135.38||||1135.38|336.64|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1135.38||||1135.38|145.77|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|1135.38||||1135.38|567.69|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1135.38||||1135.38|783.41|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1135.38||||1135.38|38.95|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1135.38||||1135.38|145.77|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1135.38||||1135.38|414.84|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1135.38||||1135.38|336.64|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1135.38||||1135.38|145.77|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1135.38||||1135.38|414.84|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1135.38||||1135.38|336.64|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1135.38||||1135.38|336.64|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1135.38||||1135.38|783.41|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1135.38||||1135.38|336.64|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|Self-pay|Self-pay|1135.38||||1135.38|397.38|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1135.38||||1135.38|336.64|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1135.38||||1135.38|336.64|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1135.38||||1135.38|373.1|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1135.38||||1135.38|145.77|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1135.38||||1135.38|145.77|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1135.38||||1135.38|373.1|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1135.38||||1135.38|145.77|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1135.38||||1135.38|291.53|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|2270.75||||2270.75|746.2|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2270.75||||2270.75|294.45|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|2270.75||||2270.75|829.68|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2270.75||||2270.75|673.28|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2270.75||||2270.75|291.53|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2270.75||||2270.75|291.53|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|2270.75||||2270.75|1067.25|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2270.75||||2270.75|0|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2270.75||||2270.75|1135.38|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2270.75||||2270.75|1430.57|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2270.75||||2270.75|673.28|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2270.75||||2270.75|291.53|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|2270.75||||2270.75|1135.38|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2270.75||||2270.75|1566.82|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2270.75||||2270.75|38.95|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2270.75||||2270.75|291.53|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2270.75||||2270.75|829.68|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2270.75||||2270.75|673.28|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2270.75||||2270.75|291.53|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2270.75||||2270.75|829.68|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2270.75||||2270.75|673.28|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2270.75||||2270.75|673.28|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2270.75||||2270.75|1566.82|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2270.75||||2270.75|673.28|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|2270.75||||2270.75|794.76|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2270.75||||2270.75|673.28|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2270.75||||2270.75|673.28|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2270.75||||2270.75|746.2|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2270.75||||2270.75|291.53|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2270.75||||2270.75|291.53|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2270.75||||2270.75|746.2|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2270.75||||2270.75|291.53|1566.82|38.95
179601|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2270.75||||2270.75|583.06|1566.82|38.95
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|6438.7||||6438.7|2839.47|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6438.7||||6438.7|1909.07|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|6438.7||||6438.7|3026.19|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6438.7||||6438.7|3219.35|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6438.7||||6438.7|3219.35|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6438.7||||6438.7|4056.38|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6438.7||||6438.7|1909.07|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|6438.7||||6438.7|3219.35|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6438.7||||6438.7|4442.7|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6438.7||||6438.7|3219.35|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6438.7||||6438.7|2839.47|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6438.7||||6438.7|1909.07|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6438.7||||6438.7|2839.47|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6438.7||||6438.7|1909.07|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6438.7||||6438.7|1909.07|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6438.7||||6438.7|4442.7|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6438.7||||6438.7|1909.07|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|6438.7||||6438.7|2253.54|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6438.7||||6438.7|1909.07|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6438.7||||6438.7|1909.07|4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6438.7||||6438.7||4442.7|1909.07
181287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MARGETUXIMAB-CMKB 25 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6438.7||||6438.7||4442.7|1909.07
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
181784|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CASIRIVIMAB 120 MG/ML-IMDEVIMAB 120 MG/ML INTRAVENOUS SOLUTION (EUA)|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|70.37||||70.37|38.4|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70.37||||70.37|20.86|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|70.37||||70.37|33.07|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70.37||||70.37|0|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70.37||||70.37|35.19|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70.37||||70.37|44.33|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70.37||||70.37|20.86|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|70.37||||70.37|38.7|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|70.37||||70.37|48.56|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70.37||||70.37|0.09|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70.37||||70.37|38.4|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70.37||||70.37|20.86|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70.37||||70.37|38.4|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70.37||||70.37|20.86|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|70.37||||70.37|20.86|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|70.37||||70.37|48.56|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70.37||||70.37|20.86|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|Self-pay|Self-pay|70.37||||70.37|24.63|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70.37||||70.37|20.86|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70.37||||70.37|20.86|48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70.37||||70.37||48.56|0.09
18194|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70.37||||70.37||48.56|0.09
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|17.41||||17.41|7.68|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.41||||17.41|5.16|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|17.41||||17.41|8.18|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.41||||17.41|8.71|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.41||||17.41|8.71|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.41||||17.41|10.97|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.41||||17.41|5.16|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|17.41||||17.41|9.58|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|17.41||||17.41|12.01|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.41||||17.41|8.71|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.41||||17.41|7.68|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.41||||17.41|5.16|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.41||||17.41|7.68|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.41||||17.41|5.16|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.41||||17.41|5.16|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|17.41||||17.41|12.01|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.41||||17.41|5.16|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|Self-pay|Self-pay|17.41||||17.41|6.09|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.41||||17.41|5.16|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.41||||17.41|5.16|12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.41||||17.41||12.01|5.16
1821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|COLCHICINE 0.6 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.41||||17.41||12.01|5.16
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|32145.08||||32145.08|14175.98|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32145.08||||32145.08|9531.02|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|32145.08||||32145.08|15108.19|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32145.08||||32145.08|16072.54|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32145.08||||32145.08|16072.54|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32145.08||||32145.08|20251.4|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32145.08||||32145.08|9531.02|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|32145.08||||32145.08|16072.54|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|32145.08||||32145.08|22180.11|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|32145.08||||32145.08|16072.54|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32145.08||||32145.08|14175.98|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32145.08||||32145.08|9531.02|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32145.08||||32145.08|14175.98|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32145.08||||32145.08|9531.02|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|32145.08||||32145.08|9531.02|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|32145.08||||32145.08|22180.11|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32145.08||||32145.08|9531.02|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|32145.08||||32145.08|11250.78|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|32145.08||||32145.08|9531.02|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32145.08||||32145.08|9531.02|22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32145.08||||32145.08||22180.11|9531.02
182340|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOSTARLIMAB-GXLY 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32145.08||||32145.08||22180.11|9531.02
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|AARP [1000]|AARP [100000]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|AETNA [1015]|AETNA [101529]|37.98||||37.98|16.75|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.98||||37.98|11.26|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|BCBS [1155]|BCBS UTHCT [115568]|37.98||||37.98|17.85|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.98||||37.98|18.99|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.98||||37.98|18.99|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.98||||37.98|23.93|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.98||||37.98|11.26|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|CIGNA [1260]|CIGNA GWH [126023]|37.98||||37.98|20.89|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|37.98||||37.98|26.21|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|37.98||||37.98|18.99|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.98||||37.98|16.75|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.98||||37.98|11.26|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.98||||37.98|16.75|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.98||||37.98|11.26|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|37.98||||37.98|11.26|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|37.98||||37.98|26.21|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.98||||37.98|11.26|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|Self-pay|Self-pay|37.98||||37.98|13.29|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|37.98||||37.98|11.26|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.98||||37.98|11.26|26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.98||||37.98||26.21|11.26
18262|ERX|0250 - PHARMACY-GENERAL|TRACE ELEMENTS CR-CU-MN-ZN 10 MCG-1 MG-0.5 MG-5 MG/ML INTRAVENOUS SOLN|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.98||||37.98||26.21|11.26
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.86||||2.86|1.26|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.86||||2.86|0.85|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.86||||2.86|1.34|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.86||||2.86|1.43|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.86||||2.86|1.43|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.86||||2.86|1.8|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.86||||2.86|0.85|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.86||||2.86|1.57|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.86||||2.86|1.97|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.86||||2.86|1.43|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.86||||2.86|1.26|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.86||||2.86|0.85|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.86||||2.86|1.26|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.86||||2.86|0.85|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.86||||2.86|0.85|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.86||||2.86|1.97|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.86||||2.86|0.85|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.86||||2.86|1|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.86||||2.86|0.85|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.86||||2.86|0.85|1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.86||||2.86||1.97|0.85
18288|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISOPROLOL FUMARATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.86||||2.86||1.97|0.85
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|AARP [1000]|AARP [100000]|175.53||||175.53||121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175.53||||175.53|45.64|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|AETNA [1015]|AETNA [101529]|175.53||||175.53|77.41|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175.53||||175.53|52.04|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175.53||||175.53|45.64|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175.53||||175.53|45.64|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|BCBS [1155]|BCBS UTHCT [115568]|175.53||||175.53|82.5|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175.53||||175.53|0|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175.53||||175.53|87.77|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175.53||||175.53|110.58|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175.53||||175.53|52.04|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175.53||||175.53|45.64|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|CIGNA [1260]|CIGNA GWH [126023]|175.53||||175.53|96.54|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|175.53||||175.53|121.12|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|175.53||||175.53|76.23|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175.53||||175.53|45.64|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175.53||||175.53|77.41|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175.53||||175.53|52.04|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175.53||||175.53|45.64|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175.53||||175.53|77.41|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175.53||||175.53|52.04|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|175.53||||175.53|52.04|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|175.53||||175.53|121.12|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175.53||||175.53|52.04|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|Self-pay|Self-pay|175.53||||175.53|61.44|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|175.53||||175.53|52.04|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175.53||||175.53|52.04|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175.53||||175.53||121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|175.53||||175.53|45.64|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|175.53||||175.53|45.64|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175.53||||175.53||121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175.53||||175.53|45.64|121.12|45.64
182958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS2021-22(65YR UP)(PF)240 MCG/0.7 ML INTRAMUSCULAR SYRINGE|0.7 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175.53||||175.53|91.28|121.12|45.64
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|53.88||||53.88||37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|53.88||||53.88|14.01|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|53.88||||53.88|23.76|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|53.88||||53.88|15.98|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|53.88||||53.88|14.01|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|53.88||||53.88|14.01|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|53.88||||53.88|25.32|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|53.88||||53.88|0|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|53.88||||53.88|26.94|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|53.88||||53.88|33.94|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|53.88||||53.88|15.98|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|53.88||||53.88|14.01|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|53.88||||53.88|29.63|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|53.88||||53.88|37.18|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|53.88||||53.88|24.48|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|53.88||||53.88|14.01|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|53.88||||53.88|23.76|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|53.88||||53.88|15.98|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|53.88||||53.88|14.01|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|53.88||||53.88|23.76|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|53.88||||53.88|15.98|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|53.88||||53.88|15.98|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|53.88||||53.88|37.18|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|53.88||||53.88|15.98|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|53.88||||53.88|18.86|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|53.88||||53.88|15.98|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|53.88||||53.88|15.98|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|53.88||||53.88||37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|53.88||||53.88|14.01|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|53.88||||53.88|14.01|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|53.88||||53.88||37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|53.88||||53.88|14.01|37.18|14.01
182960|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLU VACCINE QS 2021-22(6MOS UP)(PF) 60 MCG(15 MCGX4)/0.5 ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|53.88||||53.88|28.02|37.18|14.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AARP [1000]|AARP [100000]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AETNA [1015]|AETNA [101529]|21.29||||21.29|16.13|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.29||||21.29|6.31|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS [1155]|BCBS UTHCT [115568]|21.29||||21.29|10.01|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.29||||21.29|0|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.29||||21.29|10.65|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.29||||21.29|13.41|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.29||||21.29|6.31|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|CIGNA [1260]|CIGNA GWH [126023]|21.29||||21.29|11.71|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|21.29||||21.29|14.69|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.29||||21.29|2.01|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.29||||21.29|16.13|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.29||||21.29|6.31|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.29||||21.29|16.13|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.29||||21.29|6.31|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.29||||21.29|6.31|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|21.29||||21.29|14.69|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.29||||21.29|6.31|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|Self-pay|Self-pay|21.29||||21.29|7.45|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.29||||21.29|6.31|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.29||||21.29|6.31|16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.29||||21.29||16.13|2.01
18302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 4.5 GRAM INTRAVENOUS SOLUTION|4.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.29||||21.29||16.13|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AARP [1000]|AARP [100000]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AETNA [1015]|AETNA [101529]|17.05||||17.05|8.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.05||||17.05|5.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS [1155]|BCBS UTHCT [115568]|17.05||||17.05|8.01|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.05||||17.05|0|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.05||||17.05|8.53|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.05||||17.05|10.74|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.05||||17.05|5.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|CIGNA [1260]|CIGNA GWH [126023]|17.05||||17.05|9.38|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|GROUP PENSION ADMIN [1450]|GPA [145000]|17.05||||17.05|11.76|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.05||||17.05|2.01|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.05||||17.05|8.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.05||||17.05|5.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.05||||17.05|8.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.05||||17.05|5.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.05||||17.05|5.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|PHCS [1780]|PHCS MULTIPLAN [178000]|17.05||||17.05|11.76|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.05||||17.05|5.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|Self-pay|Self-pay|17.05||||17.05|5.97|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.05||||17.05|5.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.05||||17.05|5.06|11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.05||||17.05||11.76|2.01
18304|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PIPERACILLIN-TAZOBACTAM 2.25 GRAM INTRAVENOUS SOLUTION|2.25 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.05||||17.05||11.76|2.01
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.57||||1.57|0.69|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.57||||1.57|0.47|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.57||||1.57|0.74|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.57||||1.57|0.79|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.57||||1.57|0.79|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.57||||1.57|0.99|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.57||||1.57|0.47|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.57||||1.57|0.86|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.57||||1.57|1.08|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.57||||1.57|0.79|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.57||||1.57|0.69|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.57||||1.57|0.47|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.57||||1.57|0.69|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.57||||1.57|0.47|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.57||||1.57|0.47|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.57||||1.57|1.08|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.57||||1.57|0.47|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|Self-pay|Self-pay|1.57||||1.57|0.55|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.57||||1.57|0.47|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.57||||1.57|0.47|1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.57||||1.57||1.08|0.47
18310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.57||||1.57||1.08|0.47
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.47||||1.47|0.65|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.47||||1.47|0.44|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.47||||1.47|0.69|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.47||||1.47|0.74|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.47||||1.47|0.74|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.47||||1.47|0.93|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.47||||1.47|0.44|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.47||||1.47|0.81|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.47||||1.47|1.01|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.47||||1.47|0.74|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.47||||1.47|0.65|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.47||||1.47|0.44|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.47||||1.47|0.65|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.47||||1.47|0.44|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.47||||1.47|0.44|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.47||||1.47|1.01|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.47||||1.47|0.44|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|Self-pay|Self-pay|1.47||||1.47|0.51|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.47||||1.47|0.44|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.47||||1.47|0.44|1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.47||||1.47||1.01|0.44
18311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.47||||1.47||1.01|0.44
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.57||||1.57|0.69|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.57||||1.57|0.47|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.57||||1.57|0.74|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.57||||1.57|0.79|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.57||||1.57|0.79|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.57||||1.57|0.99|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.57||||1.57|0.47|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.57||||1.57|0.86|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.57||||1.57|1.08|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.57||||1.57|0.79|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.57||||1.57|0.69|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.57||||1.57|0.47|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.57||||1.57|0.69|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.57||||1.57|0.47|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.57||||1.57|0.47|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.57||||1.57|1.08|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.57||||1.57|0.47|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|Self-pay|Self-pay|1.57||||1.57|0.55|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.57||||1.57|0.47|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.57||||1.57|0.47|1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.57||||1.57||1.08|0.47
18312|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.57||||1.57||1.08|0.47
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.3||||1.3|0.57|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.3||||1.3|0.39|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.3||||1.3|0.61|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.3||||1.3|0.65|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.3||||1.3|0.65|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.3||||1.3|0.82|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.3||||1.3|0.39|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.3||||1.3|0.72|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.3||||1.3|0.9|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.3||||1.3|0.65|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.3||||1.3|0.57|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.3||||1.3|0.39|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.3||||1.3|0.57|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.3||||1.3|0.39|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.3||||1.3|0.39|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.3||||1.3|0.9|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.3||||1.3|0.39|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|Self-pay|Self-pay|1.3||||1.3|0.45|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.3||||1.3|0.39|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.3||||1.3|0.39|0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.3||||1.3||0.9|0.39
18313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.3||||1.3||0.9|0.39
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AARP [1000]|AARP [100000]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|2.21||||2.21|0.97|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.21||||2.21|0.66|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.21||||2.21|1.04|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.21||||2.21|1.11|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.21||||2.21|1.11|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.21||||2.21|1.39|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.21||||2.21|0.66|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.21||||2.21|1.22|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.21||||2.21|1.52|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.21||||2.21|1.11|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.21||||2.21|0.97|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.21||||2.21|0.66|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.21||||2.21|0.97|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.21||||2.21|0.66|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.21||||2.21|0.66|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.21||||2.21|1.52|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.21||||2.21|0.66|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|Self-pay|Self-pay|2.21||||2.21|0.77|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.21||||2.21|0.66|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.21||||2.21|0.66|1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.21||||2.21||1.52|0.66
18385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 100 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.21||||2.21||1.52|0.66
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.82||||1.82|0.8|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.82||||1.82|0.54|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.82||||1.82|0.86|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.82||||1.82|0.91|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.82||||1.82|0.91|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.82||||1.82|1.15|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.82||||1.82|0.54|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.82||||1.82|1|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.82||||1.82|1.26|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.82||||1.82|0.91|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.82||||1.82|0.8|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.82||||1.82|0.54|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.82||||1.82|0.8|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.82||||1.82|0.54|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.82||||1.82|0.54|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.82||||1.82|1.26|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.82||||1.82|0.54|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|Self-pay|Self-pay|1.82||||1.82|0.64|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.82||||1.82|0.54|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.82||||1.82|0.54|1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.82||||1.82||1.26|0.54
18386|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 150 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.82||||1.82||1.26|0.54
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.26||||0.26|0.11|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.26||||0.26|0.08|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.26||||0.26|0.12|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.26||||0.26|0.13|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.26||||0.26|0.13|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.26||||0.26|0.16|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.26||||0.26|0.08|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.26||||0.26|0.14|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.26||||0.26|0.18|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.26||||0.26|0.13|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.26||||0.26|0.11|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.26||||0.26|0.08|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.26||||0.26|0.11|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.26||||0.26|0.08|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.26||||0.26|0.08|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.26||||0.26|0.18|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.26||||0.26|0.08|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|Self-pay|Self-pay|0.26||||0.26|0.09|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.26||||0.26|0.08|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.26||||0.26|0.08|0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.26||||0.26||0.18|0.08
18551|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARVEDILOL 3.125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.26||||0.26||0.18|0.08
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AARP [1000]|AARP [100000]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AETNA [1015]|AETNA [101529]|33.17||||33.17|14.63|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.17||||33.17|9.83|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|33.17||||33.17|15.59|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.17||||33.17|16.59|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.17||||33.17|16.59|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.17||||33.17|20.9|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.17||||33.17|9.83|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|33.17||||33.17|18.24|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33.17||||33.17|22.89|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.17||||33.17|16.59|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.17||||33.17|14.63|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.17||||33.17|9.83|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.17||||33.17|14.63|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.17||||33.17|9.83|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.17||||33.17|9.83|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33.17||||33.17|22.89|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.17||||33.17|9.83|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|Self-pay|Self-pay|33.17||||33.17|11.61|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.17||||33.17|9.83|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.17||||33.17|9.83|22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.17||||33.17||22.89|9.83
18621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LATANOPROST 0.005 % EYE DROPS|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.17||||33.17||22.89|9.83
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.42||||0.42|0.19|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.42||||0.42|0.12|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.42||||0.42|0.2|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.42||||0.42|0.21|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.42||||0.42|0.21|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.42||||0.42|0.26|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.42||||0.42|0.12|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.42||||0.42|0.23|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.42||||0.42|0.29|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.42||||0.42|0.21|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.42||||0.42|0.19|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.42||||0.42|0.12|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.42||||0.42|0.19|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.42||||0.42|0.12|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.42||||0.42|0.12|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.42||||0.42|0.29|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.42||||0.42|0.12|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.42||||0.42|0.15|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.42||||0.42|0.12|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.42||||0.42|0.12|0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.42||||0.42||0.29|0.12
18786|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.42||||0.42|0.19|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.42||||0.42|0.12|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.42||||0.42|0.2|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.42||||0.42|0.21|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.42||||0.42|0.21|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.42||||0.42|0.26|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.42||||0.42|0.12|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.42||||0.42|0.23|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.42||||0.42|0.29|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.42||||0.42|0.21|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.42||||0.42|0.19|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.42||||0.42|0.12|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.42||||0.42|0.19|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.42||||0.42|0.12|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.42||||0.42|0.12|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.42||||0.42|0.29|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.42||||0.42|0.12|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.42||||0.42|0.15|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.42||||0.42|0.12|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.42||||0.42|0.12|0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.42||||0.42||0.29|0.12
18787|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DONEPEZIL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.42||||0.42||0.29|0.12
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|248||||248|109.37|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|248||||248|73.53|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|248||||248|116.56|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|248||||248|124|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|248||||248|124|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|248||||248|156.24|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|248||||248|73.53|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|248||||248|136.4|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|248||||248|171.12|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|248||||248|124|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|248||||248|109.37|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|248||||248|73.53|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|248||||248|109.37|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|248||||248|73.53|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|248||||248|73.53|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|248||||248|171.12|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|248||||248|73.53|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|248||||248|86.8|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|248||||248|73.53|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|248||||248|73.53|171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|248||||248||171.12|73.53
18908|ERX|0250 - PHARMACY-GENERAL|SODIUM NITROPRUSSIDE 25 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|248||||248||171.12|73.53
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.76||||0.76|0.34|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.76||||0.76|0.23|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.76||||0.76|0.36|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.76||||0.76|0.38|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.76||||0.76|0.38|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.76||||0.76|0.48|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.76||||0.76|0.23|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.76||||0.76|0.42|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.76||||0.76|0.52|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.76||||0.76|0.38|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.76||||0.76|0.34|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.76||||0.76|0.23|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.76||||0.76|0.34|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.76||||0.76|0.23|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.76||||0.76|0.23|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.76||||0.76|0.52|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.76||||0.76|0.23|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.76||||0.76|0.27|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.76||||0.76|0.23|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.76||||0.76|0.23|0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.76||||0.76||0.52|0.23
18919|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.76||||0.76||0.52|0.23
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.21||||0.21|0.09|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.21||||0.21|0.06|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.21||||0.21|0.1|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.21||||0.21|0.11|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.21||||0.21|0.11|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.21||||0.21|0.13|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.21||||0.21|0.06|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.21||||0.21|0.12|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.21||||0.21|0.14|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.21||||0.21|0.11|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.21||||0.21|0.09|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.21||||0.21|0.06|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.21||||0.21|0.09|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.21||||0.21|0.06|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.21||||0.21|0.06|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.21||||0.21|0.14|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.21||||0.21|0.06|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.21||||0.21|0.07|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.21||||0.21|0.06|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.21||||0.21|0.06|0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.21||||0.21||0.14|0.06
18920|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.21||||0.21||0.14|0.06
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.48||||1.48|0.65|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.48||||1.48|0.44|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.48||||1.48|0.7|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.48||||1.48|0.74|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.48||||1.48|0.74|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.48||||1.48|0.93|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.48||||1.48|0.44|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.48||||1.48|0.81|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.48||||1.48|1.02|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.48||||1.48|0.74|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.48||||1.48|0.65|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.48||||1.48|0.44|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.48||||1.48|0.65|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.48||||1.48|0.44|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.48||||1.48|0.44|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.48||||1.48|1.02|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.48||||1.48|0.44|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|Self-pay|Self-pay|1.48||||1.48|0.52|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.48||||1.48|0.44|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.48||||1.48|0.44|1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.48||||1.48||1.02|0.44
18922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOPIRAMATE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.48||||1.48||1.02|0.44
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|49.6||||49.6|1.92|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49.6||||49.6|14.71|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|49.6||||49.6|23.31|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49.6||||49.6|0|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49.6||||49.6|24.8|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49.6||||49.6|31.25|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49.6||||49.6|14.71|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|49.6||||49.6|27.28|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|49.6||||49.6|34.22|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|49.6||||49.6|0.49|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49.6||||49.6|1.92|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49.6||||49.6|14.71|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49.6||||49.6|1.92|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49.6||||49.6|14.71|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|49.6||||49.6|14.71|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|49.6||||49.6|34.22|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49.6||||49.6|14.71|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|49.6||||49.6|17.36|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|49.6||||49.6|14.71|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49.6||||49.6|14.71|34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49.6||||49.6||34.22|0.49
18925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVOFLOXACIN 25 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49.6||||49.6||34.22|0.49
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.51||||0.51|0.22|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.51||||0.51|0.15|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.51||||0.51|0.24|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.51||||0.51|0.26|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.51||||0.51|0.26|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.51||||0.51|0.32|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.51||||0.51|0.15|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.51||||0.51|0.28|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.51||||0.51|0.35|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.51||||0.51|0.26|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.51||||0.51|0.22|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.51||||0.51|0.15|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.51||||0.51|0.22|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.51||||0.51|0.15|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.51||||0.51|0.15|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.51||||0.51|0.35|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.51||||0.51|0.15|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.51||||0.51|0.18|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.51||||0.51|0.15|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.51||||0.51|0.15|0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.51||||0.51||0.35|0.15
19146|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 12.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.51||||0.51||0.35|0.15
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.15||||1.15|0.51|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.15||||1.15|0.34|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.15||||1.15|0.54|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.15||||1.15|0.58|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.15||||1.15|0.58|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.15||||1.15|0.72|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.15||||1.15|0.34|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.15||||1.15|0.63|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.15||||1.15|0.79|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.15||||1.15|0.58|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.15||||1.15|0.51|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.15||||1.15|0.34|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.15||||1.15|0.51|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.15||||1.15|0.34|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.15||||1.15|0.34|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.15||||1.15|0.79|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.15||||1.15|0.34|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.15||||1.15|0.4|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.15||||1.15|0.34|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.15||||1.15|0.34|0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.15||||1.15||0.79|0.34
19176|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.15||||1.15||0.79|0.34
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.4||||1.4|0.62|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.4||||1.4|0.42|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.4||||1.4|0.66|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.4||||1.4|0.7|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.4||||1.4|0.7|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.4||||1.4|0.88|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.4||||1.4|0.42|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.4||||1.4|0.77|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.4||||1.4|0.97|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.4||||1.4|0.7|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.4||||1.4|0.62|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.4||||1.4|0.42|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.4||||1.4|0.62|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.4||||1.4|0.42|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.4||||1.4|0.42|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.4||||1.4|0.97|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.4||||1.4|0.42|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|Self-pay|Self-pay|1.4||||1.4|0.49|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.4||||1.4|0.42|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.4||||1.4|0.42|0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.4||||1.4||0.97|0.42
19177|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.4||||1.4|0.62|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.4||||1.4|0.42|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.4||||1.4|0.66|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.4||||1.4|0.7|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.4||||1.4|0.7|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.4||||1.4|0.88|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.4||||1.4|0.42|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.4||||1.4|0.77|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.4||||1.4|0.97|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.4||||1.4|0.7|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.4||||1.4|0.62|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.4||||1.4|0.42|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.4||||1.4|0.62|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.4||||1.4|0.42|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.4||||1.4|0.42|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.4||||1.4|0.97|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.4||||1.4|0.42|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|Self-pay|Self-pay|1.4||||1.4|0.49|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.4||||1.4|0.42|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.4||||1.4|0.42|0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.4||||1.4||0.97|0.42
19178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATORVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.4||||1.4||0.97|0.42
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.05||||1.05|0.46|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.05||||1.05|0.31|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.05||||1.05|0.49|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.05||||1.05|0.53|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.05||||1.05|0.53|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.05||||1.05|0.66|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.05||||1.05|0.31|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.05||||1.05|0.58|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.05||||1.05|0.72|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.05||||1.05|0.53|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.05||||1.05|0.46|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.05||||1.05|0.31|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.05||||1.05|0.46|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.05||||1.05|0.31|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.05||||1.05|0.31|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.05||||1.05|0.72|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.05||||1.05|0.31|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|Self-pay|Self-pay|1.05||||1.05|0.37|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.05||||1.05|0.31|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.05||||1.05|0.31|0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.05||||1.05||0.72|0.31
19433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.05||||1.05||0.72|0.31
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AARP [1000]|AARP [100000]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AETNA [1015]|AETNA [101529]|18.65||||18.65|8.22|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.65||||18.65|5.53|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|BCBS [1155]|BCBS UTHCT [115568]|18.65||||18.65|8.77|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.65||||18.65|9.33|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.65||||18.65|9.33|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.65||||18.65|11.75|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.65||||18.65|5.53|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|CIGNA [1260]|CIGNA GWH [126023]|18.65||||18.65|10.26|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|GROUP PENSION ADMIN [1450]|GPA [145000]|18.65||||18.65|12.87|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.65||||18.65|9.33|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.65||||18.65|8.22|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.65||||18.65|5.53|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.65||||18.65|8.22|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.65||||18.65|5.53|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.65||||18.65|5.53|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|PHCS [1780]|PHCS MULTIPLAN [178000]|18.65||||18.65|12.87|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.65||||18.65|5.53|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|Self-pay|Self-pay|18.65||||18.65|6.53|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.65||||18.65|5.53|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.65||||18.65|5.53|12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.65||||18.65||12.87|5.53
19436|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 98 % ORAL POWDER FOR SUSPENSION|334 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.65||||18.65||12.87|5.53
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|74.59||||74.59|32.89|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74.59||||74.59|22.12|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|74.59||||74.59|35.06|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74.59||||74.59|0|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74.59||||74.59|37.3|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74.59||||74.59|46.99|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74.59||||74.59|22.12|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|74.59||||74.59|41.02|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|74.59||||74.59|51.47|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74.59||||74.59|37.3|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74.59||||74.59|32.89|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74.59||||74.59|22.12|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74.59||||74.59|32.89|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74.59||||74.59|22.12|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|74.59||||74.59|22.12|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|74.59||||74.59|51.47|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74.59||||74.59|22.12|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|74.59||||74.59|26.11|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74.59||||74.59|22.12|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74.59||||74.59|22.12|51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74.59||||74.59||51.47|22.12
19451|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPH,PERTUS(ACEL),TET PED(PF) 25 LF UNIT-58 MCG-10 LF/0.5ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74.59||||74.59||51.47|22.12
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|77.5||||77.5|34.18|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|77.5||||77.5|22.98|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|77.5||||77.5|36.43|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|77.5||||77.5|38.75|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|77.5||||77.5|38.75|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|77.5||||77.5|48.83|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|77.5||||77.5|22.98|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|77.5||||77.5|42.63|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|77.5||||77.5|53.48|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|77.5||||77.5|38.75|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|77.5||||77.5|34.18|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|77.5||||77.5|22.98|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|77.5||||77.5|34.18|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|77.5||||77.5|22.98|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|77.5||||77.5|22.98|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|77.5||||77.5|53.48|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|77.5||||77.5|22.98|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|Self-pay|Self-pay|77.5||||77.5|27.12|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|77.5||||77.5|22.98|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|77.5||||77.5|22.98|53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|77.5||||77.5||53.48|22.98
19452|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLOPATADINE 0.1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|77.5||||77.5||53.48|22.98
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|AARP [1000]|AARP [100000]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|AETNA [1015]|AETNA [101529]|12.16||||12.16|5.36|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.16||||12.16|3.61|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|BCBS [1155]|BCBS UTHCT [115568]|12.16||||12.16|5.72|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.16||||12.16|6.08|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.16||||12.16|6.08|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.16||||12.16|7.66|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.16||||12.16|3.61|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|CIGNA [1260]|CIGNA GWH [126023]|12.16||||12.16|6.69|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|GROUP PENSION ADMIN [1450]|GPA [145000]|12.16||||12.16|8.39|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.16||||12.16|6.08|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.16||||12.16|5.36|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.16||||12.16|3.61|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.16||||12.16|5.36|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.16||||12.16|3.61|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.16||||12.16|3.61|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|PHCS [1780]|PHCS MULTIPLAN [178000]|12.16||||12.16|8.39|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.16||||12.16|3.61|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|Self-pay|Self-pay|12.16||||12.16|4.26|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.16||||12.16|3.61|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.16||||12.16|3.61|8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.16||||12.16||8.39|3.61
19690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 10 % MUCOSAL GEL|7 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.16||||12.16||8.39|3.61
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|AARP [1000]|AARP [100000]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|AETNA [1015]|AETNA [101529]|102.43||||102.43|45.17|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102.43||||102.43|30.37|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|BCBS [1155]|BCBS UTHCT [115568]|102.43||||102.43|48.14|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102.43||||102.43|51.22|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102.43||||102.43|51.22|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102.43||||102.43|64.53|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102.43||||102.43|30.37|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|CIGNA [1260]|CIGNA GWH [126023]|102.43||||102.43|56.34|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|GROUP PENSION ADMIN [1450]|GPA [145000]|102.43||||102.43|70.68|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102.43||||102.43|51.22|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102.43||||102.43|45.17|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102.43||||102.43|30.37|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102.43||||102.43|45.17|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102.43||||102.43|30.37|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|102.43||||102.43|30.37|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|PHCS [1780]|PHCS MULTIPLAN [178000]|102.43||||102.43|70.68|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102.43||||102.43|30.37|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|Self-pay|Self-pay|102.43||||102.43|35.85|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102.43||||102.43|30.37|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102.43||||102.43|30.37|70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102.43||||102.43||70.68|30.37
19696|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL AEROSOL SPRAY|57 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102.43||||102.43||70.68|30.37
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|99.39||||99.39|43.83|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99.39||||99.39|29.47|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|99.39||||99.39|46.71|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99.39||||99.39|49.7|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99.39||||99.39|49.7|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99.39||||99.39|62.62|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99.39||||99.39|29.47|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|99.39||||99.39|54.66|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|99.39||||99.39|68.58|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|99.39||||99.39|49.7|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99.39||||99.39|43.83|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99.39||||99.39|29.47|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99.39||||99.39|43.83|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99.39||||99.39|29.47|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|99.39||||99.39|29.47|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|99.39||||99.39|68.58|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99.39||||99.39|29.47|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|Self-pay|Self-pay|99.39||||99.39|34.79|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|99.39||||99.39|29.47|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99.39||||99.39|29.47|68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99.39||||99.39||68.58|29.47
19733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|KETOROLAC 0.5 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99.39||||99.39||68.58|29.47
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AARP [1000]|AARP [100000]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AETNA [1015]|AETNA [101529]|106.63||||106.63|47.02|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|106.63||||106.63|31.62|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|106.63||||106.63|50.12|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|106.63||||106.63|53.32|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|106.63||||106.63|53.32|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|106.63||||106.63|67.18|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|106.63||||106.63|31.62|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|106.63||||106.63|58.65|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|106.63||||106.63|73.57|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|106.63||||106.63|53.32|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106.63||||106.63|47.02|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|106.63||||106.63|31.62|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|106.63||||106.63|47.02|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|106.63||||106.63|31.62|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|106.63||||106.63|31.62|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|106.63||||106.63|73.57|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|106.63||||106.63|31.62|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|Self-pay|Self-pay|106.63||||106.63|37.32|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|106.63||||106.63|31.62|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|106.63||||106.63|31.62|73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|106.63||||106.63||73.57|31.62
19736|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 150 MG/ML INTRAMUSCULAR SUSPENSION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|106.63||||106.63||73.57|31.62
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|46.5||||46.5|20.51|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|46.5||||46.5|13.79|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|46.5||||46.5|21.86|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|46.5||||46.5|23.25|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|46.5||||46.5|23.25|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|46.5||||46.5|29.3|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|46.5||||46.5|13.79|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|46.5||||46.5|25.58|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|46.5||||46.5|32.09|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|46.5||||46.5|23.25|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|46.5||||46.5|20.51|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|46.5||||46.5|13.79|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|46.5||||46.5|20.51|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|46.5||||46.5|13.79|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|46.5||||46.5|13.79|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|46.5||||46.5|32.09|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|46.5||||46.5|13.79|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|46.5||||46.5|16.27|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|46.5||||46.5|13.79|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|46.5||||46.5|13.79|32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|46.5||||46.5||32.09|13.79
19746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OFLOXACIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|46.5||||46.5||32.09|13.79
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.16||||1.16|0.51|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.16||||1.16|0.34|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.16||||1.16|0.55|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.16||||1.16|0.58|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.16||||1.16|0.58|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.16||||1.16|0.73|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.16||||1.16|0.34|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.16||||1.16|0.64|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.16||||1.16|0.8|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.16||||1.16|0.58|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.16||||1.16|0.51|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.16||||1.16|0.34|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.16||||1.16|0.51|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.16||||1.16|0.34|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.16||||1.16|0.34|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.16||||1.16|0.8|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.16||||1.16|0.34|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|1.16||||1.16|0.41|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.16||||1.16|0.34|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.16||||1.16|0.34|0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.16||||1.16||0.8|0.34
19882|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SERTRALINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.16||||1.16||0.8|0.34
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|AARP [1000]|AARP [100000]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|AETNA [1015]|AETNA [101529]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|BCBS [1155]|BCBS UTHCT [115568]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|CIGNA [1260]|CIGNA GWH [126023]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|Self-pay|Self-pay|5064||||5064|1772.4|1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5064||||5064||1772.4|1772.4
20000000|EAP|0200 - INTENSIVE CARE-GENERAL|HC ICU ROOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5064||||5064||1772.4|1772.4
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AARP [1000]|AARP [100000]|2.15||||2.15|2.15|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.15||||2.15||2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AETNA [1015]|AETNA [101529]|2.15||||2.15|2.15|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.15||||2.15|0.64|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.15||||2.15||2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.15||||2.15||2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BCBS UTHCT [115568]|2.15||||2.15|1.01|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.15||||2.15|0|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.15||||2.15|1.08|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.15||||2.15|1.35|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.15||||2.15|0.64|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.15||||2.15||2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA GWH [126023]|2.15||||2.15|1.18|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.15||||2.15|1.48|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.15||||2.15|2.3|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.15||||2.15||2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.15||||2.15|2.15|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.15||||2.15|0.64|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.15||||2.15||2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.15||||2.15|2.15|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.15||||2.15|0.64|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.15||||2.15|0.64|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.15||||2.15|1.48|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.15||||2.15|0.64|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|Self-pay|Self-pay|2.15||||2.15|0.75|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.15||||2.15|0.64|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.15||||2.15|0.64|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.15||||2.15|2.15|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.15||||2.15||2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.15||||2.15||2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.15||||2.15|2.15|2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.15||||2.15||2.3|0.64
2007|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYANOCOBALAMIN (VIT B-12) 1,000 MCG/ML INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.15||||2.15||2.3|0.64
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.61||||0.61|0.27|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.61||||0.61|0.18|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.61||||0.61|0.29|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.61||||0.61|0.31|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.61||||0.61|0.31|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.61||||0.61|0.38|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.61||||0.61|0.18|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.61||||0.61|0.34|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.61||||0.61|0.42|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.61||||0.61|0.31|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.61||||0.61|0.27|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.61||||0.61|0.18|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.61||||0.61|0.27|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.61||||0.61|0.18|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.61||||0.61|0.18|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.61||||0.61|0.42|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.61||||0.61|0.18|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|Self-pay|Self-pay|0.61||||0.61|0.21|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.61||||0.61|0.18|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.61||||0.61|0.18|0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.61||||0.61||0.42|0.18
2012|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYANOCOBALAMIN (VIT B-12) 500 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.61||||0.61||0.42|0.18
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|64.79||||64.79|34.08|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64.79||||64.79|19.21|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|64.79||||64.79|30.45|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64.79||||64.79|0|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64.79||||64.79|32.4|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64.79||||64.79|40.82|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64.79||||64.79|19.21|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|64.79||||64.79|35.63|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|64.79||||64.79|44.71|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|64.79||||64.79|0.86|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64.79||||64.79|34.08|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64.79||||64.79|19.21|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64.79||||64.79|34.08|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64.79||||64.79|19.21|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|64.79||||64.79|19.21|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|64.79||||64.79|44.71|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64.79||||64.79|19.21|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|Self-pay|Self-pay|64.79||||64.79|22.68|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|64.79||||64.79|19.21|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64.79||||64.79|19.21|44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64.79||||64.79||44.71|0.86
20156|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYTARABINE (PF) 2 GRAM/20 ML (100 MG/ML) INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64.79||||64.79||44.71|0.86
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|AARP [1000]|AARP [100000]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|AETNA [1015]|AETNA [101529]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|BCBS [1155]|BCBS UTHCT [115568]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|CIGNA [1260]|CIGNA GWH [126023]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|Self-pay|Self-pay|5064||||5064|1772.4|1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5064||||5064||1772.4|1772.4
20200000|EAP|0202 - INTENSIVE CARE-MEDICAL|HC MEDICAL ICU ROOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5064||||5064||1772.4|1772.4
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AARP [1000]|AARP [100000]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AETNA [1015]|AETNA [101529]|36.65||||36.65|16.16|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.65||||36.65|10.87|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BCBS UTHCT [115568]|36.65||||36.65|17.23|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.65||||36.65|18.33|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.65||||36.65|18.33|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.65||||36.65|23.09|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.65||||36.65|10.87|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|CIGNA [1260]|CIGNA GWH [126023]|36.65||||36.65|20.16|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|36.65||||36.65|25.29|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|36.65||||36.65|18.33|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.65||||36.65|16.16|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.65||||36.65|10.87|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.65||||36.65|16.16|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36.65||||36.65|10.87|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|36.65||||36.65|10.87|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|36.65||||36.65|25.29|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.65||||36.65|10.87|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|Self-pay|Self-pay|36.65||||36.65|12.83|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|36.65||||36.65|10.87|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.65||||36.65|10.87|25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.65||||36.65||25.29|10.87
2025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOPENTOLATE 1 % EYE DROPS|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36.65||||36.65||25.29|10.87
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|AARP [1000]|AARP [100000]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|AETNA [1015]|AETNA [101529]|1.76||||1.76|0.78|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.76||||1.76|0.52|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1.76||||1.76|0.83|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.76||||1.76|0.88|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.76||||1.76|0.88|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.76||||1.76|1.11|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.76||||1.76|0.52|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1.76||||1.76|0.97|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.76||||1.76|1.21|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.76||||1.76|0.88|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.76||||1.76|0.78|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.76||||1.76|0.52|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.76||||1.76|0.78|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.76||||1.76|0.52|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.76||||1.76|0.52|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.76||||1.76|1.21|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.76||||1.76|0.52|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|Self-pay|Self-pay|1.76||||1.76|0.62|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.76||||1.76|0.52|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.76||||1.76|0.52|1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.76||||1.76||1.21|0.52
2032|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 2 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.76||||1.76||1.21|0.52
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.28||||0.28|0.12|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.28||||0.28|0.08|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.28||||0.28|0.13|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.28||||0.28|0.14|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.28||||0.28|0.14|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.28||||0.28|0.18|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.28||||0.28|0.08|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.28||||0.28|0.15|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.28||||0.28|0.19|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.28||||0.28|0.14|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.28||||0.28|0.12|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.28||||0.28|0.08|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.28||||0.28|0.12|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.28||||0.28|0.08|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.28||||0.28|0.08|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.28||||0.28|0.19|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.28||||0.28|0.08|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|Self-pay|Self-pay|0.28||||0.28|0.1|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.28||||0.28|0.08|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.28||||0.28|0.08|0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.28||||0.28||0.19|0.08
2033|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYPROHEPTADINE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.28||||0.28||0.19|0.08
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|AARP [1000]|AARP [100000]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|AETNA [1015]|AETNA [101529]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|BCBS [1155]|BCBS UTHCT [115568]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|CIGNA [1260]|CIGNA GWH [126023]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|Self-pay|Self-pay|2629||||2629|920.15|920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2629||||2629||920.15|920.15
20400000|EAP|0204 - INTENSIVE CARE-PSYCHIATRIC|HC PSYCHIATRIC ICU ROOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2629||||2629||920.15|920.15
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.59||||2.59|1.14|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.59||||2.59|0.77|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|2.59||||2.59|1.22|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.59||||2.59|1.3|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.59||||2.59|1.3|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.59||||2.59|1.63|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.59||||2.59|0.77|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|2.59||||2.59|1.42|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.59||||2.59|1.79|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.59||||2.59|1.3|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.59||||2.59|1.14|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.59||||2.59|0.77|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.59||||2.59|1.14|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.59||||2.59|0.77|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.59||||2.59|0.77|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.59||||2.59|1.79|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.59||||2.59|0.77|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.59||||2.59|0.91|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.59||||2.59|0.77|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.59||||2.59|0.77|1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.59||||2.59||1.79|0.77
20446|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ANAGRELIDE 0.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.59||||2.59||1.79|0.77
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|19.29||||19.29|8.51|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.29||||19.29|5.72|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|19.29||||19.29|9.07|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.29||||19.29|9.65|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.29||||19.29|9.65|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.29||||19.29|12.15|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.29||||19.29|5.72|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|19.29||||19.29|10.61|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.29||||19.29|13.31|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.29||||19.29|9.65|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.29||||19.29|8.51|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.29||||19.29|5.72|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.29||||19.29|8.51|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.29||||19.29|5.72|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.29||||19.29|5.72|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.29||||19.29|13.31|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.29||||19.29|5.72|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|19.29||||19.29|6.75|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.29||||19.29|5.72|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.29||||19.29|5.72|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.29||||19.29||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|12.4||||12.4|5.47|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.4||||12.4|3.68|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|12.4||||12.4|5.83|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.4||||12.4|6.2|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.4||||12.4|6.2|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.4||||12.4|7.81|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.4||||12.4|3.68|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|12.4||||12.4|6.82|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.4||||12.4|8.56|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.4||||12.4|6.2|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.4||||12.4|5.47|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.4||||12.4|3.68|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.4||||12.4|5.47|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.4||||12.4|3.68|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.4||||12.4|3.68|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.4||||12.4|8.56|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.4||||12.4|3.68|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|12.4||||12.4|4.34|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.4||||12.4|3.68|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.4||||12.4|3.68|13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.4||||12.4||13.31|3.68
20472|ERX|0250 - PHARMACY-GENERAL|ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.4||||12.4||13.31|3.68
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.13||||0.13|0.06|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.13||||0.13|0.04|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.13||||0.13|0.06|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.13||||0.13|0.07|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.13||||0.13|0.07|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.13||||0.13|0.08|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.13||||0.13|0.04|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.13||||0.13|0.07|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.13||||0.13|0.09|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.13||||0.13|0.07|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.13||||0.13|0.06|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.13||||0.13|0.04|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.13||||0.13|0.06|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.13||||0.13|0.04|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.13||||0.13|0.04|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.13||||0.13|0.09|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.13||||0.13|0.04|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.13||||0.13|0.05|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.13||||0.13|0.04|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.13||||0.13|0.04|0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.13||||0.13||0.09|0.04
20566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MELOXICAM 7.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.13||||0.13||0.09|0.04
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|AARP [1000]|AARP [100000]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|AETNA [1015]|AETNA [101529]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|BCBS [1155]|BCBS UTHCT [115568]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|CIGNA [1260]|CIGNA GWH [126023]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|Self-pay|Self-pay|2629||||2629|920.15|920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2629||||2629||920.15|920.15
20600000|EAP|0206 - INTENSIVE CARE-INTERMEDIATE ICU|HC INTERMEDIATE ICU ROOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2629||||2629||920.15|920.15
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|3321.37||||3321.37|2725.66|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3321.37||||3321.37|984.79|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|3321.37||||3321.37|1561.04|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3321.37||||3321.37|0|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3321.37||||3321.37|1660.69|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3321.37||||3321.37|2092.46|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3321.37||||3321.37|984.79|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|3321.37||||3321.37|1660.69|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|3321.37||||3321.37|2291.75|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3321.37||||3321.37|1419.61|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3321.37||||3321.37|2725.66|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3321.37||||3321.37|984.79|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3321.37||||3321.37|2725.66|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3321.37||||3321.37|984.79|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|3321.37||||3321.37|984.79|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|3321.37||||3321.37|2291.75|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3321.37||||3321.37|984.79|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|3321.37||||3321.37|1162.48|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3321.37||||3321.37|984.79|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3321.37||||3321.37|984.79|2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3321.37||||3321.37||2725.66|984.79
20803|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIFOSTINE CRYSTALLINE 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3321.37||||3321.37||2725.66|984.79
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|20.77||||20.77|9.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.77||||20.77|6.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|20.77||||20.77|9.76|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.77||||20.77|10.39|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.77||||20.77|10.39|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.77||||20.77|13.09|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.77||||20.77|6.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|20.77||||20.77|11.42|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|20.77||||20.77|14.33|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.77||||20.77|10.39|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.77||||20.77|9.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.77||||20.77|6.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.77||||20.77|9.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.77||||20.77|6.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.77||||20.77|6.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|20.77||||20.77|14.33|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.77||||20.77|6.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|20.77||||20.77|7.27|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.77||||20.77|6.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.77||||20.77|6.16|14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.77||||20.77||14.33|6.16
20887|ERX|0250 - PHARMACY-GENERAL|VALPROATE SODIUM 500 MG/5 ML (100 MG/ML) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.77||||20.77||14.33|6.16
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|50.88||||50.88|20.86|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.88||||50.88||35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|50.88||||50.88|20.5|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.88||||50.88|15.09|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.88||||50.88||35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.88||||50.88||35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|50.88||||50.88|23.91|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.88||||50.88|0|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.88||||50.88|25.44|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.88||||50.88|32.05|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.88||||50.88|15.09|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.88||||50.88||35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|50.88||||50.88|27.98|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|50.88||||50.88|35.11|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50.88||||50.88|6.06|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.88||||50.88||35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.88||||50.88|20.5|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.88||||50.88|15.09|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.88||||50.88||35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.88||||50.88|20.5|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.88||||50.88|15.09|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|50.88||||50.88|15.09|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|50.88||||50.88|35.11|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.88||||50.88|15.09|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|50.88||||50.88|17.81|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50.88||||50.88|15.09|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.88||||50.88|15.09|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.88||||50.88|20.86|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50.88||||50.88||35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50.88||||50.88||35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.88||||50.88|20.86|35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.88||||50.88||35.11|6.06
2091|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DACARBAZINE 200 MG INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.88||||50.88||35.11|6.06
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.39||||5.39|2.38|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.39||||5.39|1.6|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.39||||5.39|2.53|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.39||||5.39|2.7|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.39||||5.39|2.7|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.39||||5.39|3.4|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.39||||5.39|1.6|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.39||||5.39|2.96|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.39||||5.39|3.72|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.39||||5.39|2.7|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.39||||5.39|2.38|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.39||||5.39|1.6|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.39||||5.39|2.38|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.39||||5.39|1.6|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.39||||5.39|1.6|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.39||||5.39|3.72|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.39||||5.39|1.6|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|Self-pay|Self-pay|5.39||||5.39|1.89|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.39||||5.39|1.6|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.39||||5.39|1.6|3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.39||||5.39||3.72|1.6
20943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AZITHROMYCIN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.39||||5.39||3.72|1.6
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|AARP [1000]|AARP [100000]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|AETNA [1015]|AETNA [101529]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|BCBS [1155]|BCBS UTHCT [115568]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|CIGNA [1260]|CIGNA GWH [126023]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|Self-pay|Self-pay|3743||||3743|1310.05|1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3743||||3743||1310.05|1310.05
21000000|EAP|0210 - CORONARY CARE-GENERAL|HC CORONARY CARE GENERAL ROOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3743||||3743||1310.05|1310.05
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|AARP [1000]|AARP [100000]|13793.8||||13793.8|6896.9|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13793.8||||13793.8|4261.29|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|AETNA [1015]|AETNA [101529]|13793.8||||13793.8|8959.25|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13793.8||||13793.8|4089.86|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13793.8||||13793.8|4219.1|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13793.8||||13793.8|4219.1|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|BCBS [1155]|BCBS UTHCT [115568]|13793.8||||13793.8|6483.09|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13793.8||||13793.8|0|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13793.8||||13793.8|6896.9|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13793.8||||13793.8|8690.09|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13793.8||||13793.8|4089.86|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13793.8||||13793.8|4219.1|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|CIGNA [1260]|CIGNA GWH [126023]|13793.8||||13793.8|6896.9|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|13793.8||||13793.8|9517.72|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13793.8||||13793.8|1977.66|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13793.8||||13793.8|4219.1|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13793.8||||13793.8|8959.25|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13793.8||||13793.8|4089.86|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13793.8||||13793.8|4219.1|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13793.8||||13793.8|8959.25|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13793.8||||13793.8|4089.86|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|13793.8||||13793.8|4089.86|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|13793.8||||13793.8|9517.72|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13793.8||||13793.8|4089.86|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|Self-pay|Self-pay|13793.8||||13793.8|4827.83|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13793.8||||13793.8|4089.86|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13793.8||||13793.8|4089.86|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13793.8||||13793.8|6896.9|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13793.8||||13793.8|4219.1|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13793.8||||13793.8|4219.1|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13793.8||||13793.8|6896.9|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13793.8||||13793.8|4219.1|9517.72|1977.66
21044|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|11.25 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13793.8||||13793.8|8438.2|9517.72|1977.66
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|AARP [1000]|AARP [100000]|16437.26||||16437.26|8218.63|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16437.26||||16437.26|421.44|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|AETNA [1015]|AETNA [101529]|16437.26||||16437.26|1482.41|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16437.26||||16437.26|4873.65|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16437.26||||16437.26|417.27|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16437.26||||16437.26|417.27|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|BCBS [1155]|BCBS UTHCT [115568]|16437.26||||16437.26|7725.51|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16437.26||||16437.26|0|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16437.26||||16437.26|8218.63|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16437.26||||16437.26|10355.47|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16437.26||||16437.26|4873.65|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16437.26||||16437.26|417.27|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|CIGNA [1260]|CIGNA GWH [126023]|16437.26||||16437.26|8218.63|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|16437.26||||16437.26|11341.71|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16437.26||||16437.26|286.16|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16437.26||||16437.26|417.27|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16437.26||||16437.26|1482.41|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16437.26||||16437.26|4873.65|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16437.26||||16437.26|417.27|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16437.26||||16437.26|1482.41|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16437.26||||16437.26|4873.65|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|16437.26||||16437.26|4873.65|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|16437.26||||16437.26|11341.71|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16437.26||||16437.26|4873.65|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|Self-pay|Self-pay|16437.26||||16437.26|5753.04|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16437.26||||16437.26|4873.65|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16437.26||||16437.26|4873.65|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16437.26||||16437.26|8218.63|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16437.26||||16437.26|417.27|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16437.26||||16437.26|417.27|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16437.26||||16437.26|8218.63|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16437.26||||16437.26|417.27|11341.71|286.16
21045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT|22.5 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16437.26||||16437.26|834.54|11341.71|286.16
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.37||||1.37|0.6|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.37||||1.37|0.41|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.37||||1.37|0.64|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.37||||1.37|0.69|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.37||||1.37|0.69|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.37||||1.37|0.86|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.37||||1.37|0.41|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.37||||1.37|0.75|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.37||||1.37|0.95|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.37||||1.37|0.69|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.37||||1.37|0.6|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.37||||1.37|0.41|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.37||||1.37|0.6|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.37||||1.37|0.41|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.37||||1.37|0.41|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.37||||1.37|0.95|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.37||||1.37|0.41|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.37||||1.37|0.48|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.37||||1.37|0.41|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.37||||1.37|0.41|0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.37||||1.37||0.95|0.41
21057|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.37||||1.37||0.95|0.41
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.71||||1.71|0.75|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.71||||1.71|0.51|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.71||||1.71|0.8|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.71||||1.71|0.86|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.71||||1.71|0.86|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.71||||1.71|1.08|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.71||||1.71|0.51|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.71||||1.71|0.94|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.71||||1.71|1.18|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.71||||1.71|0.86|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.71||||1.71|0.75|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.71||||1.71|0.51|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.71||||1.71|0.75|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.71||||1.71|0.51|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.71||||1.71|0.51|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.71||||1.71|1.18|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.71||||1.71|0.51|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|Self-pay|Self-pay|1.71||||1.71|0.6|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.71||||1.71|0.51|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.71||||1.71|0.51|1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.71||||1.71||1.18|0.51
21061|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.71||||1.71||1.18|0.51
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.16||||0.16|0.07|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.16||||0.16|0.05|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.16||||0.16|0.08|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.16||||0.16|0.08|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.16||||0.16|0.08|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.16||||0.16|0.1|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.16||||0.16|0.05|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.16||||0.16|0.09|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.16||||0.16|0.11|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.16||||0.16|0.08|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.16||||0.16|0.07|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.16||||0.16|0.05|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.16||||0.16|0.07|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.16||||0.16|0.05|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.16||||0.16|0.05|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.16||||0.16|0.11|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.16||||0.16|0.05|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.16||||0.16|0.06|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.16||||0.16|0.05|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.16||||0.16|0.05|0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.16||||0.16||0.11|0.05
21062|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.16||||0.16||0.11|0.05
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|15.5||||15.5|8.21|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|4.13|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|8.21|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|8.21|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|4.13
21063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZITHROMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|4.13
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.41||||2.41|1.06|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.41||||2.41|0.71|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|2.41||||2.41|1.13|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.41||||2.41|1.21|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.41||||2.41|1.21|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.41||||2.41|1.52|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.41||||2.41|0.71|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|2.41||||2.41|1.33|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.41||||2.41|1.66|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.41||||2.41|1.21|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.41||||2.41|1.06|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.41||||2.41|0.71|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.41||||2.41|1.06|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.41||||2.41|0.71|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.41||||2.41|0.71|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.41||||2.41|1.66|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.41||||2.41|0.71|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.41||||2.41|0.84|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.41||||2.41|0.71|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.41||||2.41|0.71|1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.41||||2.41||1.66|0.71
21086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 40 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.41||||2.41||1.66|0.71
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AARP [1000]|AARP [100000]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AETNA [1015]|AETNA [101529]|29.33||||29.33|12.93|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.33||||29.33|8.7|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS [1155]|BCBS UTHCT [115568]|29.33||||29.33|13.79|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.33||||29.33|14.67|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.33||||29.33|14.67|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.33||||29.33|18.48|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.33||||29.33|8.7|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|CIGNA [1260]|CIGNA GWH [126023]|29.33||||29.33|16.13|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|29.33||||29.33|20.24|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29.33||||29.33|14.67|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.33||||29.33|12.93|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.33||||29.33|8.7|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.33||||29.33|12.93|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.33||||29.33|8.7|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29.33||||29.33|8.7|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|29.33||||29.33|20.24|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.33||||29.33|8.7|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|Self-pay|Self-pay|29.33||||29.33|10.27|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29.33||||29.33|8.7|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.33||||29.33|8.7|20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.33||||29.33||20.24|8.7
2110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM HYPOCHLORITE 0.5 % SOLUTION (DAKIN'S)|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.33||||29.33||20.24|8.7
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|AARP [1000]|AARP [100000]|21916.38||||21916.38|10958.19|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21916.38||||21916.38|561.92|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|AETNA [1015]|AETNA [101529]|21916.38||||21916.38|1976.54|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21916.38||||21916.38|6498.21|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21916.38||||21916.38|556.36|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21916.38||||21916.38|556.36|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|BCBS [1155]|BCBS UTHCT [115568]|21916.38||||21916.38|10300.7|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21916.38||||21916.38|0|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21916.38||||21916.38|10958.19|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21916.38||||21916.38|13807.32|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21916.38||||21916.38|6498.21|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21916.38||||21916.38|556.36|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|CIGNA [1260]|CIGNA GWH [126023]|21916.38||||21916.38|10958.19|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|21916.38||||21916.38|15122.3|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21916.38||||21916.38|286.16|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21916.38||||21916.38|556.36|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21916.38||||21916.38|1976.54|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21916.38||||21916.38|6498.21|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21916.38||||21916.38|556.36|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21916.38||||21916.38|1976.54|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21916.38||||21916.38|6498.21|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|21916.38||||21916.38|6498.21|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|21916.38||||21916.38|15122.3|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21916.38||||21916.38|6498.21|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|Self-pay|Self-pay|21916.38||||21916.38|7670.73|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21916.38||||21916.38|6498.21|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21916.38||||21916.38|6498.21|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21916.38||||21916.38|10958.19|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21916.38||||21916.38|556.36|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21916.38||||21916.38|556.36|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21916.38||||21916.38|10958.19|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21916.38||||21916.38|556.36|15122.3|286.16
21108|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT|30 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21916.38||||21916.38|1112.72|15122.3|286.16
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.48||||2.48|1.09|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.48||||2.48|0.74|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.48||||2.48|1.17|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.48||||2.48|1.24|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.48||||2.48|1.24|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.48||||2.48|1.56|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.48||||2.48|0.74|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.48||||2.48|1.36|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.48||||2.48|1.71|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.48||||2.48|1.24|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.48||||2.48|1.09|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.48||||2.48|0.74|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.48||||2.48|1.09|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.48||||2.48|0.74|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.48||||2.48|0.74|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.48||||2.48|1.71|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.48||||2.48|0.74|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|Self-pay|Self-pay|2.48||||2.48|0.87|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.48||||2.48|0.74|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.48||||2.48|0.74|1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.48||||2.48||1.71|0.74
21157|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 600 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.48||||2.48||1.71|0.74
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.46||||0.46|0.2|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.46||||0.46|0.14|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.46||||0.46|0.22|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.46||||0.46|0.23|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.46||||0.46|0.23|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.46||||0.46|0.29|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.46||||0.46|0.14|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.46||||0.46|0.25|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.46||||0.46|0.32|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.46||||0.46|0.23|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.46||||0.46|0.2|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.46||||0.46|0.14|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.46||||0.46|0.2|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.46||||0.46|0.14|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.46||||0.46|0.14|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.46||||0.46|0.32|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.46||||0.46|0.14|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|Self-pay|Self-pay|0.46||||0.46|0.16|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.46||||0.46|0.14|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.46||||0.46|0.14|0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.46||||0.46||0.32|0.14
21287|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.46||||0.46|0.2|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.46||||0.46|0.14|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.46||||0.46|0.22|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.46||||0.46|0.23|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.46||||0.46|0.23|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.46||||0.46|0.29|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.46||||0.46|0.14|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.46||||0.46|0.25|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.46||||0.46|0.32|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.46||||0.46|0.23|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.46||||0.46|0.2|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.46||||0.46|0.14|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.46||||0.46|0.2|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.46||||0.46|0.14|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.46||||0.46|0.14|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.46||||0.46|0.32|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.46||||0.46|0.14|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|Self-pay|Self-pay|0.46||||0.46|0.16|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.46||||0.46|0.14|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.46||||0.46|0.14|0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.46||||0.46||0.32|0.14
21290|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.46||||0.46||0.32|0.14
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.12||||1.12|0.49|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.12||||1.12|0.33|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.12||||1.12|0.53|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.12||||1.12|0.56|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.12||||1.12|0.56|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.12||||1.12|0.71|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.12||||1.12|0.33|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.12||||1.12|0.62|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.12||||1.12|0.77|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.12||||1.12|0.56|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.12||||1.12|0.49|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.12||||1.12|0.33|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.12||||1.12|0.49|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.12||||1.12|0.33|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.12||||1.12|0.33|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.12||||1.12|0.77|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.12||||1.12|0.33|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|1.12||||1.12|0.39|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.12||||1.12|0.33|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.12||||1.12|0.33|0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.12||||1.12||0.77|0.33
21300|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENTOXIFYLLINE ER 400 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.12||||1.12||0.77|0.33
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.68||||8.68|3.83|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.68||||8.68|2.57|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|8.68||||8.68|4.08|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.68||||8.68|4.34|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.68||||8.68|4.34|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.68||||8.68|5.47|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.68||||8.68|2.57|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|8.68||||8.68|4.77|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.68||||8.68|5.99|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.68||||8.68|4.34|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.68||||8.68|3.83|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.68||||8.68|2.57|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.68||||8.68|3.83|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.68||||8.68|2.57|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.68||||8.68|2.57|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.68||||8.68|5.99|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.68||||8.68|2.57|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|Self-pay|Self-pay|8.68||||8.68|3.04|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.68||||8.68|2.57|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.68||||8.68|2.57|5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.68||||8.68||5.99|2.57
2131|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.68||||8.68||5.99|2.57
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.08||||7.08|3.12|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.08||||7.08|2.1|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|7.08||||7.08|3.33|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.08||||7.08|3.54|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.08||||7.08|3.54|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.08||||7.08|4.46|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.08||||7.08|2.1|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|7.08||||7.08|3.89|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.08||||7.08|4.89|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.08||||7.08|3.54|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.08||||7.08|3.12|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.08||||7.08|2.1|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.08||||7.08|3.12|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.08||||7.08|2.1|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.08||||7.08|2.1|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.08||||7.08|4.89|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.08||||7.08|2.1|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|Self-pay|Self-pay|7.08||||7.08|2.48|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.08||||7.08|2.1|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.08||||7.08|2.1|4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.08||||7.08||4.89|2.1
2132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DAPSONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.08||||7.08||4.89|2.1
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.52||||1.52|1.52|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.52||||1.52|0.45|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.52||||1.52|0.71|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.52||||1.52|0|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.52||||1.52|0.76|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.52||||1.52|0.96|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.52||||1.52|0.45|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.52||||1.52|0.84|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.52||||1.52|1.05|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.52||||1.52|0.6|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.52||||1.52|1.52|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.52||||1.52|0.45|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.52||||1.52|1.52|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.52||||1.52|0.45|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.52||||1.52|0.45|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.52||||1.52|1.05|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.52||||1.52|0.45|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|Self-pay|Self-pay|1.52||||1.52|0.53|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.52||||1.52|0.45|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.52||||1.52|0.45|1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.52||||1.52||1.52|0.45
21374|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE MOFETIL 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.52||||1.52||1.52|0.45
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|AARP [1000]|AARP [100000]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|AETNA [1015]|AETNA [101529]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|BCBS [1155]|BCBS UTHCT [115568]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|CIGNA [1260]|CIGNA GWH [126023]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|Self-pay|Self-pay|3743||||3743|1310.05|1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3743||||3743||1310.05|1310.05
21400000|EAP|0214 - CORONARY CARE-INTERMEDIATE CCU|HC INTERMEDIATE CCU/TELEMETRY ROOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3743||||3743||1310.05|1310.05
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.93||||0.93|0.41|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.93||||0.93|0.28|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.93||||0.93|0.44|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.93||||0.93|0.47|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.93||||0.93|0.47|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.93||||0.93|0.59|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.93||||0.93|0.28|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.93||||0.93|0.51|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.93||||0.93|0.64|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.93||||0.93|0.47|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.93||||0.93|0.41|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.93||||0.93|0.28|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.93||||0.93|0.41|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.93||||0.93|0.28|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.93||||0.93|0.28|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.93||||0.93|0.64|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.93||||0.93|0.28|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.93||||0.93|0.33|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.93||||0.93|0.28|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.93||||0.93|0.28|0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.93||||0.93||0.64|0.28
21509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LETROZOLE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.93||||0.93||0.64|0.28
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.79||||1.79|0.79|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.79||||1.79|0.53|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.79||||1.79|0.84|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.79||||1.79|0.9|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.79||||1.79|0.9|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.79||||1.79|1.13|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.79||||1.79|0.53|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.79||||1.79|0.98|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.79||||1.79|1.24|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.79||||1.79|0.9|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.79||||1.79|0.79|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.79||||1.79|0.53|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.79||||1.79|0.79|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.79||||1.79|0.53|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.79||||1.79|0.53|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.79||||1.79|1.24|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.79||||1.79|0.53|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|Self-pay|Self-pay|1.79||||1.79|0.63|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.79||||1.79|0.53|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.79||||1.79|0.53|1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.79||||1.79||1.24|0.53
21529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.79||||1.79||1.24|0.53
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.93||||0.93|0.41|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.93||||0.93|0.28|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.93||||0.93|0.44|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.93||||0.93|0.47|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.93||||0.93|0.47|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.93||||0.93|0.59|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.93||||0.93|0.28|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.93||||0.93|0.51|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.93||||0.93|0.64|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.93||||0.93|0.47|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.93||||0.93|0.41|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.93||||0.93|0.28|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.93||||0.93|0.41|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.93||||0.93|0.28|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.93||||0.93|0.28|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.93||||0.93|0.64|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.93||||0.93|0.28|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|Self-pay|Self-pay|0.93||||0.93|0.33|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.93||||0.93|0.28|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.93||||0.93|0.28|0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.93||||0.93||0.64|0.28
21688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.93||||0.93||0.64|0.28
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.76||||1.76|0.78|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.76||||1.76|0.52|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.76||||1.76|0.83|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.76||||1.76|0.88|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.76||||1.76|0.88|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.76||||1.76|1.11|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.76||||1.76|0.52|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.76||||1.76|0.97|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.76||||1.76|1.21|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.76||||1.76|0.88|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.76||||1.76|0.78|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.76||||1.76|0.52|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.76||||1.76|0.78|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.76||||1.76|0.52|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.76||||1.76|0.52|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.76||||1.76|1.21|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.76||||1.76|0.52|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|Self-pay|Self-pay|1.76||||1.76|0.62|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.76||||1.76|0.52|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.76||||1.76|0.52|1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.76||||1.76||1.21|0.52
21689|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.76||||1.76||1.21|0.52
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.93||||0.93|0.41|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.93||||0.93|0.28|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.93||||0.93|0.44|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.93||||0.93|0.47|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.93||||0.93|0.47|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.93||||0.93|0.59|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.93||||0.93|0.28|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.93||||0.93|0.51|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.93||||0.93|0.64|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.93||||0.93|0.47|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.93||||0.93|0.41|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.93||||0.93|0.28|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.93||||0.93|0.41|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.93||||0.93|0.28|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.93||||0.93|0.28|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.93||||0.93|0.64|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.93||||0.93|0.28|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|Self-pay|Self-pay|0.93||||0.93|0.33|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.93||||0.93|0.28|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.93||||0.93|0.28|0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.93||||0.93||0.64|0.28
21690|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROPINIROLE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.93||||0.93||0.64|0.28
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.01||||1.01|0.45|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.01||||1.01|0.3|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.01||||1.01|0.47|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.01||||1.01|0.51|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.01||||1.01|0.51|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.01||||1.01|0.64|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.01||||1.01|0.3|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.01||||1.01|0.56|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.01||||1.01|0.7|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.01||||1.01|0.51|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.01||||1.01|0.45|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.01||||1.01|0.3|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.01||||1.01|0.45|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.01||||1.01|0.3|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.01||||1.01|0.3|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.01||||1.01|0.7|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.01||||1.01|0.3|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|1.01||||1.01|0.35|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.01||||1.01|0.3|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.01||||1.01|0.3|0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.01||||1.01||0.7|0.3
21823|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.01||||1.01||0.7|0.3
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.65||||1.65|0.73|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.65||||1.65|0.49|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.65||||1.65|0.78|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.65||||1.65|0.83|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.65||||1.65|0.83|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.65||||1.65|1.04|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.65||||1.65|0.49|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.65||||1.65|0.91|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.65||||1.65|1.14|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.65||||1.65|0.83|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.65||||1.65|0.73|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.65||||1.65|0.49|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.65||||1.65|0.73|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.65||||1.65|0.49|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.65||||1.65|0.49|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.65||||1.65|1.14|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.65||||1.65|0.49|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|1.65||||1.65|0.58|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.65||||1.65|0.49|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.65||||1.65|0.49|1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.65||||1.65||1.14|0.49
21824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.65||||1.65||1.14|0.49
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.26||||3.26|1.44|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.26||||3.26|0.97|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.26||||3.26|1.53|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.26||||3.26|1.63|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.26||||3.26|1.63|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.26||||3.26|2.05|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.26||||3.26|0.97|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.26||||3.26|1.79|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.26||||3.26|2.25|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.26||||3.26|1.63|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.26||||3.26|1.44|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.26||||3.26|0.97|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.26||||3.26|1.44|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.26||||3.26|0.97|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.26||||3.26|0.97|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.26||||3.26|2.25|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.26||||3.26|0.97|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|Self-pay|Self-pay|3.26||||3.26|1.14|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.26||||3.26|0.97|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.26||||3.26|0.97|2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.26||||3.26||2.25|0.97
21825|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.26||||3.26||2.25|0.97
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AARP [1000]|AARP [100000]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AETNA [1015]|AETNA [101529]|828.6||||828.6|318.48|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|828.6||||828.6|245.68|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS [1155]|BCBS UTHCT [115568]|828.6||||828.6|389.44|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|828.6||||828.6|0|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|828.6||||828.6|414.3|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|828.6||||828.6|522.02|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|828.6||||828.6|245.68|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|CIGNA [1260]|CIGNA GWH [126023]|828.6||||828.6|414.3|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|828.6||||828.6|571.73|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|828.6||||828.6|34.05|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|828.6||||828.6|318.48|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|828.6||||828.6|245.68|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|828.6||||828.6|318.48|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|828.6||||828.6|245.68|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|828.6||||828.6|245.68|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|828.6||||828.6|571.73|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|828.6||||828.6|245.68|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|Self-pay|Self-pay|828.6||||828.6|290.01|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|828.6||||828.6|245.68|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|828.6||||828.6|245.68|571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|828.6||||828.6||571.73|34.05
21900|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|828.6||||828.6||571.73|34.05
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|AARP [1000]|AARP [100000]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|AETNA [1015]|AETNA [101529]|1119.07||||1119.07|493.51|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1119.07||||1119.07|331.8|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|1119.07||||1119.07|525.96|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1119.07||||1119.07|0|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1119.07||||1119.07|559.54|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1119.07||||1119.07|705.01|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1119.07||||1119.07|331.8|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|1119.07||||1119.07|559.54|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1119.07||||1119.07|772.16|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1119.07||||1119.07|397.58|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1119.07||||1119.07|493.51|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1119.07||||1119.07|331.8|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1119.07||||1119.07|493.51|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1119.07||||1119.07|331.8|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1119.07||||1119.07|331.8|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1119.07||||1119.07|772.16|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1119.07||||1119.07|331.8|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|Self-pay|Self-pay|1119.07||||1119.07|391.67|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1119.07||||1119.07|331.8|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1119.07||||1119.07|331.8|772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1119.07||||1119.07||772.16|331.8
22120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RABIES VACCINE, PURIFIED CHICKEN EMBRYO CELL (PF) 2.5 UNIT IM SUSP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1119.07||||1119.07||772.16|331.8
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.81||||0.81|0.36|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.81||||0.81|0.24|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.81||||0.81|0.38|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.81||||0.81|0.41|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.81||||0.81|0.41|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.81||||0.81|0.51|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.81||||0.81|0.24|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.81||||0.81|0.45|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.81||||0.81|0.56|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.81||||0.81|0.41|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.81||||0.81|0.36|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.81||||0.81|0.24|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.81||||0.81|0.36|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.81||||0.81|0.24|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.81||||0.81|0.24|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.81||||0.81|0.56|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.81||||0.81|0.24|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|Self-pay|Self-pay|0.81||||0.81|0.28|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.81||||0.81|0.24|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.81||||0.81|0.24|0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.81||||0.81||0.56|0.24
22142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.81||||0.81||0.56|0.24
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.17||||7.17|3.16|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.17||||7.17|2.13|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|7.17||||7.17|3.37|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.17||||7.17|3.59|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.17||||7.17|3.59|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.17||||7.17|4.52|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.17||||7.17|2.13|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|7.17||||7.17|3.94|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.17||||7.17|4.95|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.17||||7.17|3.59|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.17||||7.17|3.16|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.17||||7.17|2.13|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.17||||7.17|3.16|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.17||||7.17|2.13|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.17||||7.17|2.13|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.17||||7.17|4.95|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.17||||7.17|2.13|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|Self-pay|Self-pay|7.17||||7.17|2.51|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.17||||7.17|2.13|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.17||||7.17|2.13|4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.17||||7.17||4.95|2.13
22143|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RALOXIFENE 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.17||||7.17||4.95|2.13
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.65||||9.65|4.26|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.65||||9.65|2.86|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|9.65||||9.65|4.54|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.65||||9.65|4.83|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.65||||9.65|4.83|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.65||||9.65|6.08|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.65||||9.65|2.86|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|9.65||||9.65|5.31|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.65||||9.65|6.66|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.65||||9.65|4.83|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.65||||9.65|4.26|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.65||||9.65|2.86|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.65||||9.65|4.26|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.65||||9.65|2.86|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.65||||9.65|2.86|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.65||||9.65|6.66|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.65||||9.65|2.86|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|Self-pay|Self-pay|9.65||||9.65|3.38|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.65||||9.65|2.86|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.65||||9.65|2.86|6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.65||||9.65||6.66|2.86
22243|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FINASTERIDE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.65||||9.65||6.66|2.86
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|AARP [1000]|AARP [100000]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|AETNA [1015]|AETNA [101529]|1030.63||||1030.63|454.51|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1030.63||||1030.63|305.58|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|BCBS [1155]|BCBS UTHCT [115568]|1030.63||||1030.63|484.4|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1030.63||||1030.63|515.32|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1030.63||||1030.63|515.32|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1030.63||||1030.63|649.3|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1030.63||||1030.63|305.58|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|CIGNA [1260]|CIGNA GWH [126023]|1030.63||||1030.63|566.85|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1030.63||||1030.63|711.13|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1030.63||||1030.63|515.32|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1030.63||||1030.63|454.51|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1030.63||||1030.63|305.58|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1030.63||||1030.63|454.51|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1030.63||||1030.63|305.58|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|1030.63||||1030.63|305.58|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1030.63||||1030.63|711.13|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1030.63||||1030.63|305.58|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|Self-pay|Self-pay|1030.63||||1030.63|360.72|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1030.63||||1030.63|305.58|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1030.63||||1030.63|305.58|711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1030.63||||1030.63||711.13|305.58
22251|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MUPIROCIN CALCIUM 2 % TOPICAL CREAM|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1030.63||||1030.63||711.13|305.58
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.75||||3.75|1.65|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.75||||3.75|1.11|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|3.75||||3.75|1.76|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.75||||3.75|1.88|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.75||||3.75|1.88|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.75||||3.75|2.36|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.75||||3.75|1.11|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|3.75||||3.75|2.06|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.75||||3.75|2.59|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.75||||3.75|1.88|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.75||||3.75|1.65|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.75||||3.75|1.11|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.75||||3.75|1.65|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.75||||3.75|1.11|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.75||||3.75|1.11|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.75||||3.75|2.59|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.75||||3.75|1.11|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|Self-pay|Self-pay|3.75||||3.75|1.31|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.75||||3.75|1.11|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.75||||3.75|1.11|2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.75||||3.75||2.59|1.11
22289|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFDINIR 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.75||||3.75||2.59|1.11
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|AARP [1000]|AARP [100000]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.23||||0.23|0.1|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.23||||0.23|0.07|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.23||||0.23|0.11|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.23||||0.23|0.12|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.23||||0.23|0.12|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.23||||0.23|0.14|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.23||||0.23|0.07|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.23||||0.23|0.13|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.23||||0.23|0.16|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.23||||0.23|0.12|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.23||||0.23|0.1|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.23||||0.23|0.07|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.23||||0.23|0.1|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.23||||0.23|0.07|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.23||||0.23|0.07|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.23||||0.23|0.16|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.23||||0.23|0.07|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|Self-pay|Self-pay|0.23||||0.23|0.08|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.23||||0.23|0.07|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.23||||0.23|0.07|0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.23||||0.23||0.16|0.07
22469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTASE 3,000 UNIT TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.23||||0.23||0.16|0.07
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|11.63||||11.63|1.48|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.63||||11.63||8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|11.63||||11.63|1.39|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.63||||11.63|3.45|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.63||||11.63||8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.63||||11.63||8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|11.63||||11.63|5.47|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.63||||11.63|0|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.63||||11.63|5.82|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.63||||11.63|7.33|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.63||||11.63|3.45|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.63||||11.63||8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|11.63||||11.63|6.4|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.63||||11.63|8.02|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.63||||11.63|0.49|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.63||||11.63||8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.63||||11.63|1.39|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.63||||11.63|3.45|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.63||||11.63||8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.63||||11.63|1.39|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.63||||11.63|3.45|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.63||||11.63|3.45|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.63||||11.63|8.02|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.63||||11.63|3.45|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|11.63||||11.63|4.07|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.63||||11.63|3.45|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.63||||11.63|3.45|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.63||||11.63|1.48|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.63||||11.63||8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.63||||11.63||8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.63||||11.63|1.48|8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.63||||11.63||8.02|0.49
22472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 15 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.63||||11.63||8.02|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|7.75||||7.75|1.48|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.75||||7.75||5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|7.75||||7.75|1.39|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.75||||7.75|2.3|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.75||||7.75||5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.75||||7.75||5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|7.75||||7.75|3.64|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.75||||7.75|0|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.75||||7.75|3.88|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.75||||7.75|4.88|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.75||||7.75|2.3|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.75||||7.75||5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|7.75||||7.75|4.26|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.75||||7.75|5.35|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.75||||7.75|0.49|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.75||||7.75||5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.75||||7.75|1.39|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.75||||7.75|2.3|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.75||||7.75||5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.75||||7.75|1.39|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.75||||7.75|2.3|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.75||||7.75|2.3|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.75||||7.75|5.35|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.75||||7.75|2.3|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|7.75||||7.75|2.71|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.75||||7.75|2.3|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.75||||7.75|2.3|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.75||||7.75|1.48|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.75||||7.75||5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.75||||7.75||5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.75||||7.75|1.48|5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.75||||7.75||5.35|0.49
22473|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 30 MG/ML (1 ML) INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.75||||7.75||5.35|0.49
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.55||||1.55|0.68|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.55||||1.55|0.46|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.55||||1.55|0.73|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.55||||1.55|0.78|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.55||||1.55|0.78|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.55||||1.55|0.98|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.55||||1.55|0.46|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.55||||1.55|0.85|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.55||||1.55|1.07|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.55||||1.55|0.78|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.55||||1.55|0.68|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.55||||1.55|0.46|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.55||||1.55|0.68|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.55||||1.55|0.46|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.55||||1.55|0.46|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.55||||1.55|1.07|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.55||||1.55|0.46|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.55||||1.55|0.54|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.55||||1.55|0.46|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.55||||1.55|0.46|1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.55||||1.55||1.07|0.46
22509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MONTELUKAST 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.55||||1.55||1.07|0.46
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AARP [1000]|AARP [100000]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AETNA [1015]|AETNA [101529]|11.72||||11.72|5.17|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.72||||11.72|3.47|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS [1155]|BCBS UTHCT [115568]|11.72||||11.72|5.51|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.72||||11.72|5.86|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.72||||11.72|5.86|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.72||||11.72|7.38|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.72||||11.72|3.47|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|CIGNA [1260]|CIGNA GWH [126023]|11.72||||11.72|6.45|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.72||||11.72|8.09|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.72||||11.72|5.86|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.72||||11.72|5.17|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.72||||11.72|3.47|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.72||||11.72|5.17|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.72||||11.72|3.47|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.72||||11.72|3.47|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.72||||11.72|8.09|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.72||||11.72|3.47|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|Self-pay|Self-pay|11.72||||11.72|4.1|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.72||||11.72|3.47|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.72||||11.72|3.47|8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.72||||11.72||8.09|3.47
22560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFAMETHOXAZOLE 200 MG-TRIMETHOPRIM 40 MG/5 ML ORAL SUSPENSION REPACK|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.72||||11.72||8.09|3.47
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.8||||0.8|0.35|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.8||||0.8|0.24|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.8||||0.8|0.38|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.8||||0.8|0.4|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.8||||0.8|0.4|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.8||||0.8|0.5|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.8||||0.8|0.24|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.8||||0.8|0.44|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.8||||0.8|0.55|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.8||||0.8|0.4|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.8||||0.8|0.35|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.8||||0.8|0.24|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.8||||0.8|0.35|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.8||||0.8|0.24|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.8||||0.8|0.24|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.8||||0.8|0.55|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.8||||0.8|0.24|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|Self-pay|Self-pay|0.8||||0.8|0.28|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.8||||0.8|0.24|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.8||||0.8|0.24|0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.8||||0.8||0.55|0.24
22588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOSARTAN 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.8||||0.8||0.55|0.24
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AARP [1000]|AARP [100000]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|828.01||||828.01|365.15|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|828.01||||828.01|245.5|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|828.01||||828.01|389.16|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|828.01||||828.01|414.01|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|828.01||||828.01|414.01|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|828.01||||828.01|521.65|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|828.01||||828.01|245.5|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|828.01||||828.01|455.41|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|828.01||||828.01|571.33|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|828.01||||828.01|414.01|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|828.01||||828.01|365.15|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|828.01||||828.01|245.5|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|828.01||||828.01|365.15|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|828.01||||828.01|245.5|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|828.01||||828.01|245.5|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|828.01||||828.01|571.33|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|828.01||||828.01|245.5|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|Self-pay|Self-pay|828.01||||828.01|289.8|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|828.01||||828.01|245.5|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|828.01||||828.01|245.5|571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|828.01||||828.01||571.33|245.5
22710|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOTEPREDNOL ETABONATE 0.5 % EYE DROPS,SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|828.01||||828.01||571.33|245.5
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.46||||0.46|0.2|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.46||||0.46|0.14|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.46||||0.46|0.22|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.46||||0.46|0.23|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.46||||0.46|0.23|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.46||||0.46|0.29|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.46||||0.46|0.14|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.46||||0.46|0.25|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.46||||0.46|0.32|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.46||||0.46|0.23|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.46||||0.46|0.2|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.46||||0.46|0.14|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.46||||0.46|0.2|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.46||||0.46|0.14|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.46||||0.46|0.14|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.46||||0.46|0.32|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.46||||0.46|0.14|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.46||||0.46|0.16|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.46||||0.46|0.14|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.46||||0.46|0.14|0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.46||||0.46||0.32|0.14
22719|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAMIPEXOLE 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.46||||0.46||0.32|0.14
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|AARP [1000]|AARP [100000]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|AETNA [1015]|AETNA [101529]|979.2||||979.2|431.83|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|979.2||||979.2|290.33|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|979.2||||979.2|460.22|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|979.2||||979.2|489.6|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|979.2||||979.2|489.6|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|979.2||||979.2|616.9|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|979.2||||979.2|290.33|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|979.2||||979.2|538.56|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|979.2||||979.2|675.65|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|979.2||||979.2|489.6|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|979.2||||979.2|431.83|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|979.2||||979.2|290.33|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|979.2||||979.2|431.83|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|979.2||||979.2|290.33|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|979.2||||979.2|290.33|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|979.2||||979.2|675.65|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|979.2||||979.2|290.33|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|Self-pay|Self-pay|979.2||||979.2|342.72|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|979.2||||979.2|290.33|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|979.2||||979.2|290.33|675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|979.2||||979.2||675.65|290.33
22986|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.2 %-HYDROCORTISONE 1 % EAR DROPS,SUSPENSION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|979.2||||979.2||675.65|290.33
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|23.61||||23.61|10.41|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.61||||23.61|7|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|23.61||||23.61|11.1|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.61||||23.61|11.81|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.61||||23.61|11.81|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.61||||23.61|14.87|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.61||||23.61|7|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|23.61||||23.61|12.99|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23.61||||23.61|16.29|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.61||||23.61|11.81|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.61||||23.61|10.41|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.61||||23.61|7|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.61||||23.61|10.41|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.61||||23.61|7|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.61||||23.61|7|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23.61||||23.61|16.29|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.61||||23.61|7|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|23.61||||23.61|8.26|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.61||||23.61|7|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.61||||23.61|7|16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.61||||23.61||16.29|7
22988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 500 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.61||||23.61||16.29|7
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|6.51||||6.51|2.87|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.51||||6.51|1.93|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|6.51||||6.51|3.06|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.51||||6.51|3.26|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.51||||6.51|3.26|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.51||||6.51|4.1|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.51||||6.51|1.93|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|6.51||||6.51|3.58|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|6.51||||6.51|4.49|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.51||||6.51|3.26|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.51||||6.51|2.87|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.51||||6.51|1.93|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.51||||6.51|2.87|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.51||||6.51|1.93|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.51||||6.51|1.93|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|6.51||||6.51|4.49|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.51||||6.51|1.93|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|6.51||||6.51|2.28|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.51||||6.51|1.93|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.51||||6.51|1.93|4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.51||||6.51||4.49|1.93
23122|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROGESTERONE MICRONIZED 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.51||||6.51||4.49|1.93
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|58.28||||58.28|16.8|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58.28||||58.28|17.28|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|58.28||||58.28|27.39|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58.28||||58.28|0|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58.28||||58.28|29.14|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58.28||||58.28|36.72|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58.28||||58.28|17.28|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|58.28||||58.28|32.05|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|58.28||||58.28|40.21|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58.28||||58.28|0.05|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58.28||||58.28|16.8|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58.28||||58.28|17.28|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58.28||||58.28|16.8|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.28||||58.28|17.28|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|58.28||||58.28|17.28|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|58.28||||58.28|40.21|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58.28||||58.28|17.28|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|58.28||||58.28|20.4|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58.28||||58.28|17.28|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58.28||||58.28|17.28|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58.28||||58.28||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|108.5||||108.5|33.6|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.5||||108.5|32.17|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|108.5||||108.5|51|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.5||||108.5|0|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.5||||108.5|54.25|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.5||||108.5|68.36|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.5||||108.5|32.17|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|108.5||||108.5|59.68|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|108.5||||108.5|74.87|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|108.5||||108.5|0.05|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.5||||108.5|33.6|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.5||||108.5|32.17|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.5||||108.5|33.6|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.5||||108.5|32.17|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|108.5||||108.5|32.17|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|108.5||||108.5|74.87|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.5||||108.5|32.17|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|108.5||||108.5|37.97|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|108.5||||108.5|32.17|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.5||||108.5|32.17|74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.5||||108.5||74.87|0.05
23128|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACYCLOVIR SODIUM 50 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.5||||108.5||74.87|0.05
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|0.5||||0.5|0.22|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.5||||0.5|0.15|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.5||||0.5|0.24|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.5||||0.5|0.25|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.5||||0.5|0.25|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.5||||0.5|0.32|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.5||||0.5|0.15|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.5||||0.5|0.28|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.5||||0.5|0.35|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.5||||0.5|0.25|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.5||||0.5|0.22|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.5||||0.5|0.15|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.5||||0.5|0.22|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.5||||0.5|0.15|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.5||||0.5|0.15|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.5||||0.5|0.35|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.5||||0.5|0.15|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|Self-pay|Self-pay|0.5||||0.5|0.17|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.5||||0.5|0.15|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.5||||0.5|0.15|0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.5||||0.5||0.35|0.15
2320|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG/5 ML ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.5||||0.5||0.35|0.15
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.54||||0.54|0.24|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.54||||0.54|0.16|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.54||||0.54|0.25|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.54||||0.54|0.27|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.54||||0.54|0.27|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.54||||0.54|0.34|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.54||||0.54|0.16|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.54||||0.54|0.3|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.54||||0.54|0.37|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.54||||0.54|0.27|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.54||||0.54|0.24|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.54||||0.54|0.16|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.54||||0.54|0.24|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.54||||0.54|0.16|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.54||||0.54|0.16|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.54||||0.54|0.37|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.54||||0.54|0.16|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.54||||0.54|0.19|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.54||||0.54|0.16|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.54||||0.54|0.16|0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.54||||0.54||0.37|0.16
2322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.54||||0.54||0.37|0.16
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.96||||0.96|0.42|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.96||||0.96|0.28|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.96||||0.96|0.45|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.96||||0.96|0.48|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.96||||0.96|0.48|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.96||||0.96|0.6|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.96||||0.96|0.28|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.96||||0.96|0.53|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.96||||0.96|0.66|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.96||||0.96|0.48|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.96||||0.96|0.42|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.96||||0.96|0.28|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.96||||0.96|0.42|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.96||||0.96|0.28|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.96||||0.96|0.28|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.96||||0.96|0.66|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.96||||0.96|0.28|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.96||||0.96|0.34|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.96||||0.96|0.28|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.96||||0.96|0.28|0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.96||||0.96||0.66|0.28
2324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.96||||0.96||0.66|0.28
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.54||||1.54|0.68|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.54||||1.54|0.46|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.54||||1.54|0.72|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.54||||1.54|0.77|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.54||||1.54|0.77|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.54||||1.54|0.97|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.54||||1.54|0.46|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.54||||1.54|0.85|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.54||||1.54|1.06|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.54||||1.54|0.77|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.54||||1.54|0.68|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.54||||1.54|0.46|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.54||||1.54|0.68|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.54||||1.54|0.46|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.54||||1.54|0.46|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.54||||1.54|1.06|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.54||||1.54|0.46|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|Self-pay|Self-pay|1.54||||1.54|0.54|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.54||||1.54|0.46|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.54||||1.54|0.46|1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.54||||1.54||1.06|0.46
2326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXAMETHASONE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.54||||1.54||1.06|0.46
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.12||||3.12|3.12|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.12||||3.12|0.93|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.12||||3.12|1.47|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.12||||3.12|0|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.12||||3.12|1.56|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.12||||3.12|1.97|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.12||||3.12|0.93|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.12||||3.12|1.72|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.12||||3.12|2.15|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.12||||3.12|0.14|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.12||||3.12|3.12|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.12||||3.12|0.93|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.12||||3.12|3.12|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.12||||3.12|0.93|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.12||||3.12|0.93|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.12||||3.12|2.15|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.12||||3.12|0.93|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|Self-pay|Self-pay|3.12||||3.12|1.09|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.12||||3.12|0.93|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.12||||3.12|0.93|3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.12||||3.12||3.12|0.14
2327|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.12||||3.12||3.12|0.14
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|4.43||||4.43|2.3|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|4.43||||4.43|2.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.43||||4.43|1.31|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|4.43||||4.43|2.08|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.43||||4.43|0|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.43||||4.43|2.22|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.43||||4.43|2.79|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.43||||4.43|1.31|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|4.43||||4.43|2.44|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.43||||4.43|3.06|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.43||||4.43|0.18|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.43||||4.43|2.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.43||||4.43|1.31|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.43||||4.43|2.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.43||||4.43|1.31|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.43||||4.43|1.31|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.43||||4.43|3.06|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.43||||4.43|1.31|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|4.43||||4.43|1.55|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.43||||4.43|1.31|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.43||||4.43|1.31|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.43||||4.43|2.3|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.43||||4.43|2.3|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.43||||4.43||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|40.06||||40.06|23|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40.06||||40.06||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|40.06||||40.06|28.8|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40.06||||40.06|11.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40.06||||40.06||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40.06||||40.06||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|40.06||||40.06|18.83|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40.06||||40.06|0|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40.06||||40.06|20.03|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40.06||||40.06|25.24|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40.06||||40.06|11.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40.06||||40.06||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|40.06||||40.06|22.03|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|40.06||||40.06|27.64|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|40.06||||40.06|0.18|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40.06||||40.06||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40.06||||40.06|28.8|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40.06||||40.06|11.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40.06||||40.06||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40.06||||40.06|28.8|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40.06||||40.06|11.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|40.06||||40.06|11.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|40.06||||40.06|27.64|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40.06||||40.06|11.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|40.06||||40.06|14.02|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|40.06||||40.06|11.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40.06||||40.06|11.88|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40.06||||40.06|23|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|40.06||||40.06||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|40.06||||40.06||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40.06||||40.06|23|28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40.06||||40.06||28.8|0.18
2331|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40.06||||40.06||28.8|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|2.41||||2.41|0.92|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|2.41||||2.41|1.15|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.41||||2.41|0.71|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|2.41||||2.41|1.13|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.41||||2.41|0|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.41||||2.41|1.21|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.41||||2.41|1.52|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.41||||2.41|0.71|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|2.41||||2.41|1.33|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.41||||2.41|1.66|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.41||||2.41|0.18|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.41||||2.41|1.15|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.41||||2.41|0.71|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.41||||2.41|1.15|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.41||||2.41|0.71|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.41||||2.41|0.71|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.41||||2.41|1.66|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.41||||2.41|0.71|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|2.41||||2.41|0.84|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.41||||2.41|0.71|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.41||||2.41|0.71|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.41||||2.41|0.92|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.41||||2.41|0.92|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.41||||2.41||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|30.14||||30.14|27.6|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.14||||30.14||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|30.14||||30.14|30.14|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.14||||30.14|8.94|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.14||||30.14||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.14||||30.14||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|30.14||||30.14|14.17|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.14||||30.14|0|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.14||||30.14|15.07|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.14||||30.14|18.99|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.14||||30.14|8.94|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.14||||30.14||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|30.14||||30.14|16.58|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|30.14||||30.14|20.8|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.14||||30.14|0.18|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.14||||30.14||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.14||||30.14|30.14|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.14||||30.14|8.94|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.14||||30.14||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.14||||30.14|30.14|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.14||||30.14|8.94|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.14||||30.14|8.94|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|30.14||||30.14|20.8|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.14||||30.14|8.94|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|Self-pay|Self-pay|30.14||||30.14|10.55|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.14||||30.14|8.94|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.14||||30.14|8.94|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.14||||30.14|27.6|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.14||||30.14||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.14||||30.14||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.14||||30.14|27.6|30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.14||||30.14||30.14|0.18
2332|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.14||||30.14||30.14|0.18
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.09||||1.09|0.48|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.09||||1.09|0.32|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.09||||1.09|0.51|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.09||||1.09|0.55|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.09||||1.09|0.55|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.09||||1.09|0.69|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.09||||1.09|0.32|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.09||||1.09|0.6|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.09||||1.09|0.75|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.09||||1.09|0.55|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.09||||1.09|0.48|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.09||||1.09|0.32|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.09||||1.09|0.48|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.09||||1.09|0.32|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.09||||1.09|0.32|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.09||||1.09|0.75|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.09||||1.09|0.32|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|Self-pay|Self-pay|1.09||||1.09|0.38|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.09||||1.09|0.32|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.09||||1.09|0.32|0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.09||||1.09||0.75|0.32
23458|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.09||||1.09||0.75|0.32
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AARP [1000]|AARP [100000]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AETNA [1015]|AETNA [101529]|21.7||||21.7|9.57|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.7||||21.7|6.43|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BCBS UTHCT [115568]|21.7||||21.7|10.2|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.7||||21.7|10.85|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.7||||21.7|10.85|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.7||||21.7|13.67|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.7||||21.7|6.43|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|CIGNA [1260]|CIGNA GWH [126023]|21.7||||21.7|11.94|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|21.7||||21.7|14.97|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.7||||21.7|10.85|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.7||||21.7|9.57|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.7||||21.7|6.43|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.7||||21.7|9.57|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.7||||21.7|6.43|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.7||||21.7|6.43|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|21.7||||21.7|14.97|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.7||||21.7|6.43|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|Self-pay|Self-pay|21.7||||21.7|7.59|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.7||||21.7|6.43|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.7||||21.7|6.43|14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.7||||21.7||14.97|6.43
23461|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE 4 % TOPICAL CREAM|5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.7||||21.7||14.97|6.43
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|AARP [1000]|AARP [100000]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|AETNA [1015]|AETNA [101529]|6.98||||6.98|3.08|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.98||||6.98|2.07|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BCBS UTHCT [115568]|6.98||||6.98|3.28|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.98||||6.98|3.49|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.98||||6.98|3.49|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.98||||6.98|4.4|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.98||||6.98|2.07|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|CIGNA [1260]|CIGNA GWH [126023]|6.98||||6.98|3.84|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.98||||6.98|4.82|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.98||||6.98|3.49|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.98||||6.98|3.08|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.98||||6.98|2.07|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.98||||6.98|3.08|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.98||||6.98|2.07|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.98||||6.98|2.07|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.98||||6.98|4.82|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.98||||6.98|2.07|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|Self-pay|Self-pay|6.98||||6.98|2.44|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.98||||6.98|2.07|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.98||||6.98|2.07|4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.98||||6.98||4.82|2.07
2357|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 10 % IN WATER (D10W) INTRAVENOUS SOLUTION|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.98||||6.98||4.82|2.07
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|8.42|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|4.91|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|8.42|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|8.42|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|4.6
2364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG*|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|4.6
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|3620.25||||3620.25|1261.3|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3620.25||||3620.25|399.27|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|3620.25||||3620.25|1228.8|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3620.25||||3620.25|1073.4|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3620.25||||3620.25|395.32|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3620.25||||3620.25|395.32|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|3620.25||||3620.25|1701.52|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3620.25||||3620.25|0|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3620.25||||3620.25|1810.13|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3620.25||||3620.25|2280.76|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3620.25||||3620.25|1073.4|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3620.25||||3620.25|395.32|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|3620.25||||3620.25|1810.13|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|3620.25||||3620.25|2497.97|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3620.25||||3620.25|56.13|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3620.25||||3620.25|395.32|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3620.25||||3620.25|1228.8|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3620.25||||3620.25|1073.4|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3620.25||||3620.25|395.32|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3620.25||||3620.25|1228.8|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3620.25||||3620.25|1073.4|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|3620.25||||3620.25|1073.4|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|3620.25||||3620.25|2497.97|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3620.25||||3620.25|1073.4|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|3620.25||||3620.25|1267.09|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3620.25||||3620.25|1073.4|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3620.25||||3620.25|1073.4|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3620.25||||3620.25|1261.3|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3620.25||||3620.25|395.32|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3620.25||||3620.25|395.32|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3620.25||||3620.25|1261.3|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3620.25||||3620.25|395.32|2497.97|56.13
23796|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INFLIXIMAB 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3620.25||||3620.25|790.64|2497.97|56.13
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.23||||0.23|0.1|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.23||||0.23|0.07|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.23||||0.23|0.11|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.23||||0.23|0.12|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.23||||0.23|0.12|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.23||||0.23|0.14|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.23||||0.23|0.07|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.23||||0.23|0.13|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.23||||0.23|0.16|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.23||||0.23|0.12|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.23||||0.23|0.1|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.23||||0.23|0.07|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.23||||0.23|0.1|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.23||||0.23|0.07|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.23||||0.23|0.07|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.23||||0.23|0.16|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.23||||0.23|0.07|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.23||||0.23|0.08|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.23||||0.23|0.07|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.23||||0.23|0.07|0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.23||||0.23||0.16|0.07
2403|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.23||||0.23||0.16|0.07
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.2||||0.2|0.09|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.2||||0.2|0.06|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.2||||0.2|0.09|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.2||||0.2|0.1|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.2||||0.2|0.1|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.2||||0.2|0.13|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.2||||0.2|0.06|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.2||||0.2|0.11|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.2||||0.2|0.14|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.2||||0.2|0.1|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.2||||0.2|0.09|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.2||||0.2|0.06|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.2||||0.2|0.09|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.2||||0.2|0.06|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.2||||0.2|0.06|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.2||||0.2|0.14|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.2||||0.2|0.06|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|Self-pay|Self-pay|0.2||||0.2|0.07|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.2||||0.2|0.06|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.2||||0.2|0.06|0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.2||||0.2||0.14|0.06
2404|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.2||||0.2||0.14|0.06
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|AARP [1000]|AARP [100000]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|AETNA [1015]|AETNA [101529]|15.54||||15.54|6.85|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.54||||15.54|4.61|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|BCBS [1155]|BCBS UTHCT [115568]|15.54||||15.54|7.3|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.54||||15.54|7.77|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.54||||15.54|7.77|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.54||||15.54|9.79|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.54||||15.54|4.61|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|CIGNA [1260]|CIGNA GWH [126023]|15.54||||15.54|8.55|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|GROUP PENSION ADMIN [1450]|GPA [145000]|15.54||||15.54|10.72|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.54||||15.54|7.77|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.54||||15.54|6.85|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.54||||15.54|4.61|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.54||||15.54|6.85|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.54||||15.54|4.61|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.54||||15.54|4.61|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|PHCS [1780]|PHCS MULTIPLAN [178000]|15.54||||15.54|10.72|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.54||||15.54|4.61|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|Self-pay|Self-pay|15.54||||15.54|5.44|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.54||||15.54|4.61|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.54||||15.54|4.61|10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.54||||15.54||10.72|4.61
2412|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIBUCAINE 1 % TOPICAL OINTMENT|28 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.54||||15.54||10.72|4.61
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AARP [1000]|AARP [100000]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|260.4||||260.4|97.56|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|260.4||||260.4|77.21|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|260.4||||260.4|122.39|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|260.4||||260.4|0|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|260.4||||260.4|130.2|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|260.4||||260.4|164.05|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|260.4||||260.4|77.21|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|260.4||||260.4|143.22|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|260.4||||260.4|179.68|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|260.4||||260.4|43.3|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|260.4||||260.4|97.56|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|260.4||||260.4|77.21|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|260.4||||260.4|97.56|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|260.4||||260.4|77.21|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|260.4||||260.4|77.21|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|260.4||||260.4|179.68|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|260.4||||260.4|77.21|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|Self-pay|Self-pay|260.4||||260.4|91.14|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|260.4||||260.4|77.21|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|260.4||||260.4|77.21|179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|260.4||||260.4||179.68|43.3
2417|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DICYCLOMINE 10 MG/ML INTRAMUSCULAR SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|260.4||||260.4||179.68|43.3
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|AARP [1000]|AARP [100000]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|AETNA [1015]|AETNA [101529]|1.24||||1.24|0.55|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.24||||1.24|0.37|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.24||||1.24|0.58|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.24||||1.24|0.62|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.24||||1.24|0.62|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.24||||1.24|0.78|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.24||||1.24|0.37|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.24||||1.24|0.68|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.24||||1.24|0.86|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.24||||1.24|0.62|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.24||||1.24|0.55|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.24||||1.24|0.37|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.24||||1.24|0.55|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.24||||1.24|0.37|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.24||||1.24|0.37|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.24||||1.24|0.86|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.24||||1.24|0.37|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|Self-pay|Self-pay|1.24||||1.24|0.43|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.24||||1.24|0.37|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.24||||1.24|0.37|0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.24||||1.24||0.86|0.37
2418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICYCLOMINE 10 MG CAPSULE|2 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.24||||1.24||0.86|0.37
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|2.17||||2.17|0.96|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.17||||2.17|0.64|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.17||||2.17|1.02|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.17||||2.17|1.09|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.17||||2.17|1.09|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.17||||2.17|1.37|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.17||||2.17|0.64|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.17||||2.17|1.19|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.17||||2.17|1.5|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.17||||2.17|1.09|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.17||||2.17|0.96|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.17||||2.17|0.64|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.17||||2.17|0.96|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.17||||2.17|0.64|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.17||||2.17|0.64|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.17||||2.17|1.5|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.17||||2.17|0.64|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|2.17||||2.17|0.76|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.17||||2.17|0.64|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.17||||2.17|0.64|1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.17||||2.17||1.5|0.64
24268|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 60 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.17||||2.17||1.5|0.64
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|AARP [1000]|AARP [100000]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|AETNA [1015]|AETNA [101529]|499.48||||499.48|220.27|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|499.48||||499.48|148.1|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|BCBS [1155]|BCBS UTHCT [115568]|499.48||||499.48|234.76|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|499.48||||499.48|249.74|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|499.48||||499.48|249.74|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|499.48||||499.48|314.67|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|499.48||||499.48|148.1|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|CIGNA [1260]|CIGNA GWH [126023]|499.48||||499.48|274.71|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|499.48||||499.48|344.64|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|499.48||||499.48|249.74|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|499.48||||499.48|220.27|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|499.48||||499.48|148.1|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|499.48||||499.48|220.27|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|499.48||||499.48|148.1|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|499.48||||499.48|148.1|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|499.48||||499.48|344.64|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|499.48||||499.48|148.1|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|Self-pay|Self-pay|499.48||||499.48|174.82|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|499.48||||499.48|148.1|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|499.48||||499.48|148.1|344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|499.48||||499.48||344.64|148.1
24385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE-ACETIC ACID 1 %-2 % EAR DROPS|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|499.48||||499.48||344.64|148.1
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.55||||0.55|0.24|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.55||||0.55|0.16|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.55||||0.55|0.26|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.55||||0.55|0.28|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.55||||0.55|0.28|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.55||||0.55|0.35|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.55||||0.55|0.16|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.55||||0.55|0.3|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.55||||0.55|0.38|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.55||||0.55|0.28|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.55||||0.55|0.24|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.55||||0.55|0.16|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.55||||0.55|0.24|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.55||||0.55|0.16|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.55||||0.55|0.16|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.55||||0.55|0.38|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.55||||0.55|0.16|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|Self-pay|Self-pay|0.55||||0.55|0.19|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.55||||0.55|0.16|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.55||||0.55|0.16|0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.55||||0.55||0.38|0.16
24398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METFORMIN 1,000 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.55||||0.55||0.38|0.16
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AARP [1000]|AARP [100000]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.5||||4.5|1.98|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.5||||4.5|1.33|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.5||||4.5|2.12|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.5||||4.5|2.25|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.5||||4.5|2.25|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.5||||4.5|2.84|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.5||||4.5|1.33|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.5||||4.5|2.48|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.5||||4.5|3.11|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.5||||4.5|2.25|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.5||||4.5|1.98|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.5||||4.5|1.33|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.5||||4.5|1.98|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.5||||4.5|1.33|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.5||||4.5|1.33|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.5||||4.5|3.11|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.5||||4.5|1.33|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|Self-pay|Self-pay|4.5||||4.5|1.57|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.5||||4.5|1.33|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.5||||4.5|1.33|3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.5||||4.5||3.11|1.33
2444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 125 MCG (0.125 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AARP [1000]|AARP [100000]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.5||||4.5|1.98|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.5||||4.5|1.33|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.5||||4.5|2.12|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.5||||4.5|2.25|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.5||||4.5|2.25|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.5||||4.5|2.84|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.5||||4.5|1.33|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.5||||4.5|2.48|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.5||||4.5|3.11|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.5||||4.5|2.25|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.5||||4.5|1.98|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.5||||4.5|1.33|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.5||||4.5|1.98|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.5||||4.5|1.33|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.5||||4.5|1.33|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.5||||4.5|3.11|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.5||||4.5|1.33|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|Self-pay|Self-pay|4.5||||4.5|1.57|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.5||||4.5|1.33|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.5||||4.5|1.33|3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.5||||4.5||3.11|1.33
2445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 250 MCG (0.25 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.5||||4.5||3.11|1.33
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|2.3||||2.3|1.01|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.3||||2.3|0.68|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.3||||2.3|1.08|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.3||||2.3|1.15|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.3||||2.3|1.15|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.3||||2.3|1.45|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.3||||2.3|0.68|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.3||||2.3|1.27|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.3||||2.3|1.59|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.3||||2.3|1.15|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.3||||2.3|1.01|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.3||||2.3|0.68|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.3||||2.3|1.01|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.3||||2.3|0.68|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.3||||2.3|0.68|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.3||||2.3|1.59|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.3||||2.3|0.68|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|2.3||||2.3|0.8|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.3||||2.3|0.68|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.3||||2.3|0.68|1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.3||||2.3||1.59|0.68
24470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE ER 5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.3||||2.3||1.59|0.68
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.99||||0.99|0.44|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.99||||0.99|0.29|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.99||||0.99|0.47|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.99||||0.99|0.5|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.99||||0.99|0.5|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.99||||0.99|0.62|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.99||||0.99|0.29|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.99||||0.99|0.54|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.99||||0.99|0.68|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.99||||0.99|0.5|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.99||||0.99|0.44|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.99||||0.99|0.29|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.99||||0.99|0.44|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.99||||0.99|0.29|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.99||||0.99|0.29|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.99||||0.99|0.68|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.99||||0.99|0.29|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.99||||0.99|0.35|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.99||||0.99|0.29|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.99||||0.99|0.29|0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.99||||0.99||0.68|0.29
24473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CILOSTAZOL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.99||||0.99||0.68|0.29
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|3313.9||||3313.9|931.2|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3313.9||||3313.9|982.57|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|3313.9||||3313.9|1557.53|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3313.9||||3313.9|0|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3313.9||||3313.9|1656.95|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3313.9||||3313.9|2087.76|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3313.9||||3313.9|982.57|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|3313.9||||3313.9|1656.95|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3313.9||||3313.9|2286.59|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3313.9||||3313.9|1.1|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3313.9||||3313.9|931.2|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3313.9||||3313.9|982.57|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3313.9||||3313.9|931.2|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3313.9||||3313.9|982.57|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3313.9||||3313.9|982.57|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3313.9||||3313.9|2286.59|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3313.9||||3313.9|982.57|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|3313.9||||3313.9|1159.86|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3313.9||||3313.9|982.57|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3313.9||||3313.9|982.57|2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3313.9||||3313.9||2286.59|1.1
24513|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPOETIN ALFA 40,000 UNIT/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3313.9||||3313.9||2286.59|1.1
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|1.64||||1.64|0.72|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.64||||1.64|0.49|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.64||||1.64|0.77|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.64||||1.64|0.82|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.64||||1.64|0.82|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.64||||1.64|1.03|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.64||||1.64|0.49|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.64||||1.64|0.9|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.64||||1.64|1.13|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.64||||1.64|0.82|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.64||||1.64|0.72|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.64||||1.64|0.49|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.64||||1.64|0.72|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.64||||1.64|0.49|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.64||||1.64|0.49|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.64||||1.64|1.13|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.64||||1.64|0.49|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|1.64||||1.64|0.57|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.64||||1.64|0.49|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.64||||1.64|0.49|1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.64||||1.64||1.13|0.49
24521|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE MONONITRATE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.64||||1.64||1.13|0.49
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AARP [1000]|AARP [100000]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.08||||0.08|0.04|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.08||||0.08|0.02|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.08||||0.08|0.04|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.08||||0.08|0.04|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.08||||0.08|0.04|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.08||||0.08|0.05|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.08||||0.08|0.02|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.08||||0.08|0.04|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.08||||0.08|0.06|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.08||||0.08|0.04|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.08||||0.08|0.04|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.08||||0.08|0.02|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.08||||0.08|0.04|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.08||||0.08|0.02|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.08||||0.08|0.02|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.08||||0.08|0.06|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.08||||0.08|0.02|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|Self-pay|Self-pay|0.08||||0.08|0.03|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.08||||0.08|0.02|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.08||||0.08|0.02|0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.08||||0.08||0.06|0.02
24559|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.08||||0.08||0.06|0.02
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|34.1||||34.1|15.04|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.1||||34.1|10.11|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|34.1||||34.1|16.03|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.1||||34.1|17.05|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.1||||34.1|17.05|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.1||||34.1|21.48|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.1||||34.1|10.11|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|34.1||||34.1|18.76|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|34.1||||34.1|23.53|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34.1||||34.1|17.05|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.1||||34.1|15.04|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.1||||34.1|10.11|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.1||||34.1|15.04|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.1||||34.1|10.11|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|34.1||||34.1|10.11|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|34.1||||34.1|23.53|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.1||||34.1|10.11|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|Self-pay|Self-pay|34.1||||34.1|11.93|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34.1||||34.1|10.11|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.1||||34.1|10.11|23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.1||||34.1||23.53|10.11
24702|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.1||||34.1||23.53|10.11
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.93||||3.93|1.73|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.93||||3.93|1.17|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.93||||3.93|1.85|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.93||||3.93|1.97|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.93||||3.93|1.97|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.93||||3.93|2.48|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.93||||3.93|1.17|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.93||||3.93|2.16|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.93||||3.93|2.71|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.93||||3.93|1.97|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.93||||3.93|1.73|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.93||||3.93|1.17|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.93||||3.93|1.73|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.93||||3.93|1.17|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.93||||3.93|1.17|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.93||||3.93|2.71|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.93||||3.93|1.17|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|Self-pay|Self-pay|3.93||||3.93|1.38|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.93||||3.93|1.17|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.93||||3.93|1.17|2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.93||||3.93||2.71|1.17
24703|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MODAFINIL 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.93||||3.93||2.71|1.17
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.59||||2.59|1.14|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.59||||2.59|0.77|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.59||||2.59|1.22|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.59||||2.59|1.3|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.59||||2.59|1.3|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.59||||2.59|1.63|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.59||||2.59|0.77|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.59||||2.59|1.42|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.59||||2.59|1.79|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.59||||2.59|1.3|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.59||||2.59|1.14|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.59||||2.59|0.77|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.59||||2.59|1.14|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.59||||2.59|0.77|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.59||||2.59|0.77|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.59||||2.59|1.79|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.59||||2.59|0.77|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|Self-pay|Self-pay|2.59||||2.59|0.91|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.59||||2.59|0.77|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.59||||2.59|0.77|1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.59||||2.59||1.79|0.77
2475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.59||||2.59||1.79|0.77
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.73||||0.73|0.32|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.73||||0.73|0.22|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.73||||0.73|0.34|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.73||||0.73|0.37|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.73||||0.73|0.37|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.73||||0.73|0.46|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.73||||0.73|0.22|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.73||||0.73|0.4|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.73||||0.73|0.5|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.73||||0.73|0.37|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.73||||0.73|0.32|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.73||||0.73|0.22|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.73||||0.73|0.32|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.73||||0.73|0.22|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.73||||0.73|0.22|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.73||||0.73|0.5|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.73||||0.73|0.22|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|Self-pay|Self-pay|0.73||||0.73|0.26|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.73||||0.73|0.22|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.73||||0.73|0.22|0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.73||||0.73||0.5|0.22
2476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 60 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.73||||0.73||0.5|0.22
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1||||1|0.44|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1||||1|0.3|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1||||1|0.47|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1||||1|0.5|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1||||1|0.5|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1||||1|0.63|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1||||1|0.3|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1||||1|0.55|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1||||1|0.69|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1||||1|0.5|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1||||1|0.44|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1||||1|0.3|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1||||1|0.44|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1||||1|0.3|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1||||1|0.3|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1||||1|0.69|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1||||1|0.3|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|Self-pay|Self-pay|1||||1|0.35|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1||||1|0.3|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1||||1|0.3|0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1||||1||0.69|0.3
2477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 90 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1||||1||0.69|0.3
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AARP [1000]|AARP [100000]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AETNA [1015]|AETNA [101529]|1.47||||1.47|0.65|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.47||||1.47|0.44|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.47||||1.47|0.69|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.47||||1.47|0.74|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.47||||1.47|0.74|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.47||||1.47|0.93|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.47||||1.47|0.44|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.47||||1.47|0.81|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.47||||1.47|1.01|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.47||||1.47|0.74|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.47||||1.47|0.65|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.47||||1.47|0.44|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.47||||1.47|0.65|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.47||||1.47|0.44|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.47||||1.47|0.44|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.47||||1.47|1.01|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.47||||1.47|0.44|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|Self-pay|Self-pay|1.47||||1.47|0.51|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.47||||1.47|0.44|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.47||||1.47|0.44|1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.47||||1.47||1.01|0.44
24844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 30 MG-600 MG TABLET EXTENDED RELEASE12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.47||||1.47||1.01|0.44
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AARP [1000]|AARP [100000]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|6.15||||6.15|1.42|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.15||||6.15|1.82|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|6.15||||6.15|2.89|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.15||||6.15|0|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.15||||6.15|3.08|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.15||||6.15|3.87|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.15||||6.15|1.82|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|6.15||||6.15|3.38|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|6.15||||6.15|4.24|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.15||||6.15|0.75|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.15||||6.15|1.42|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.15||||6.15|1.82|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.15||||6.15|1.42|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.15||||6.15|1.82|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.15||||6.15|1.82|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|6.15||||6.15|4.24|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.15||||6.15|1.82|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|Self-pay|Self-pay|6.15||||6.15|2.15|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.15||||6.15|1.82|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.15||||6.15|1.82|4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.15||||6.15||4.24|0.75
24914|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TACROLIMUS 0.5 MG CAPSULE, IMMEDIATE-RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.15||||6.15||4.24|0.75
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AARP [1000]|AARP [100000]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AETNA [1015]|AETNA [101529]|98.58||||98.58|23.28|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|98.58||||98.58|29.23|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|98.58||||98.58|46.33|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|98.58||||98.58|0|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|98.58||||98.58|49.29|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|98.58||||98.58|62.11|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|98.58||||98.58|29.23|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|98.58||||98.58|54.22|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|98.58||||98.58|68.02|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|98.58||||98.58|49.29|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|98.58||||98.58|23.28|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|98.58||||98.58|29.23|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|98.58||||98.58|23.28|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|98.58||||98.58|29.23|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|98.58||||98.58|29.23|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|98.58||||98.58|68.02|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|98.58||||98.58|29.23|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|Self-pay|Self-pay|98.58||||98.58|34.5|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|98.58||||98.58|29.23|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|98.58||||98.58|29.23|68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|98.58||||98.58||68.02|23.28
24932|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|98.58||||98.58||68.02|23.28
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AARP [1000]|AARP [100000]|1.71||||1.71|1.71|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.71||||1.71||1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AETNA [1015]|AETNA [101529]|1.71||||1.71|1.71|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.71||||1.71|0.51|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.71||||1.71||1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.71||||1.71||1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BCBS UTHCT [115568]|1.71||||1.71|0.8|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.71||||1.71|0|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.71||||1.71|0.86|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.71||||1.71|1.08|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.71||||1.71|0.51|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.71||||1.71||1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|CIGNA [1260]|CIGNA GWH [126023]|1.71||||1.71|0.94|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.71||||1.71|1.18|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.71||||1.71|0.78|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.71||||1.71||1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.71||||1.71|1.71|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.71||||1.71|0.51|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.71||||1.71||1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.71||||1.71|1.71|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.71||||1.71|0.51|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.71||||1.71|0.51|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.71||||1.71|1.18|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.71||||1.71|0.51|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|Self-pay|Self-pay|1.71||||1.71|0.6|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.71||||1.71|0.51|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.71||||1.71|0.51|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.71||||1.71|1.71|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.71||||1.71||1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.71||||1.71||1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.71||||1.71|1.71|1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.71||||1.71||1.71|0.51
2508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHENHYDRAMINE 50 MG/ML INJECTION SOLUTION|0.2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.71||||1.71||1.71|0.51
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.11||||0.11|0.07|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.11||||0.11|0.03|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.11||||0.11|0.05|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.11||||0.11|0|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.11||||0.11|0.06|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.11||||0.11|0.07|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.11||||0.11|0.03|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.11||||0.11|0.06|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.11||||0.11|0.08|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.11||||0.11|0.06|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.11||||0.11|0.07|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.11||||0.11|0.03|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.11||||0.11|0.07|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.11||||0.11|0.03|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.11||||0.11|0.03|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.11||||0.11|0.08|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.11||||0.11|0.03|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.11||||0.11|0.04|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.11||||0.11|0.03|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.11||||0.11|0.03|0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.11||||0.11||0.08|0.03
2509|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.11||||0.11||0.08|0.03
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.14||||0.14|0.07|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.14||||0.14|0.04|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.14||||0.14|0.07|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.14||||0.14|0|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.14||||0.14|0.07|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.14||||0.14|0.09|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.14||||0.14|0.04|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.14||||0.14|0.08|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.14||||0.14|0.1|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.14||||0.14|0.07|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.14||||0.14|0.07|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.14||||0.14|0.04|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.14||||0.14|0.07|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.14||||0.14|0.04|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.14||||0.14|0.04|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.14||||0.14|0.1|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.14||||0.14|0.04|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.14||||0.14|0.05|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.14||||0.14|0.04|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.14||||0.14|0.04|0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.14||||0.14||0.1|0.04
2510|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.14||||0.14||0.1|0.04
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AARP [1000]|AARP [100000]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AETNA [1015]|AETNA [101529]|9.71||||9.71|0.07|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.71||||9.71|2.88|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS [1155]|BCBS UTHCT [115568]|9.71||||9.71|4.56|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.71||||9.71|0|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.71||||9.71|4.86|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.71||||9.71|6.12|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.71||||9.71|2.88|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|CIGNA [1260]|CIGNA GWH [126023]|9.71||||9.71|5.34|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.71||||9.71|6.7|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.71||||9.71|4.86|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.71||||9.71|0.07|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.71||||9.71|2.88|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.71||||9.71|0.07|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.71||||9.71|2.88|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.71||||9.71|2.88|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.71||||9.71|6.7|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.71||||9.71|2.88|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|Self-pay|Self-pay|9.71||||9.71|3.4|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.71||||9.71|2.88|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.71||||9.71|2.88|6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.71||||9.71||6.7|0.07
2511|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENHYDRAMINE 12.5 MG/5 ML ORAL ELIXIR|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.71||||9.71||6.7|0.07
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.55||||1.55|0.68|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.55||||1.55|0.46|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.55||||1.55|0.73|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.55||||1.55|0.78|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.55||||1.55|0.78|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.55||||1.55|0.98|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.55||||1.55|0.46|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.55||||1.55|0.85|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.55||||1.55|1.07|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.55||||1.55|0.78|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.55||||1.55|0.68|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.55||||1.55|0.46|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.55||||1.55|0.68|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.55||||1.55|0.46|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.55||||1.55|0.46|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.55||||1.55|1.07|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.55||||1.55|0.46|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|Self-pay|Self-pay|1.55||||1.55|0.54|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.55||||1.55|0.46|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.55||||1.55|0.46|1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.55||||1.55||1.07|0.46
2516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPHENOXYLATE-ATROPINE 2.5 MG-0.025 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.55||||1.55||1.07|0.46
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|AARP [1000]|AARP [100000]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|AETNA [1015]|AETNA [101529]|76.25||||76.25|33.63|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76.25||||76.25|22.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|BCBS [1155]|BCBS UTHCT [115568]|76.25||||76.25|35.84|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76.25||||76.25|38.13|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76.25||||76.25|38.13|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76.25||||76.25|48.04|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76.25||||76.25|22.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|CIGNA [1260]|CIGNA GWH [126023]|76.25||||76.25|41.94|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|76.25||||76.25|52.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|76.25||||76.25|38.13|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76.25||||76.25|33.63|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76.25||||76.25|22.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76.25||||76.25|33.63|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76.25||||76.25|22.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|76.25||||76.25|22.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|76.25||||76.25|52.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76.25||||76.25|22.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|Self-pay|Self-pay|76.25||||76.25|26.69|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|76.25||||76.25|22.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76.25||||76.25|22.61|52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76.25||||76.25||52.61|22.61
252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALBUTEROL SULFATE 2 MG/5 ML ORAL SYRUP|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76.25||||76.25||52.61|22.61
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|AARP [1000]|AARP [100000]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|4.52||||4.52|1.99|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.52||||4.52|1.34|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|4.52||||4.52|2.12|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.52||||4.52|2.26|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.52||||4.52|2.26|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.52||||4.52|2.85|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.52||||4.52|1.34|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|4.52||||4.52|2.49|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.52||||4.52|3.12|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.52||||4.52|2.26|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.52||||4.52|1.99|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.52||||4.52|1.34|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.52||||4.52|1.99|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.52||||4.52|1.34|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.52||||4.52|1.34|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.52||||4.52|3.12|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.52||||4.52|1.34|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|Self-pay|Self-pay|4.52||||4.52|1.58|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.52||||4.52|1.34|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.52||||4.52|1.34|3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.52||||4.52||3.12|1.34
25238|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL ER 120 MG 24 HR CAPSULE,EXTENDED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.52||||4.52||3.12|1.34
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|1.01||||1.01|0.45|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.01||||1.01|0.3|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1.01||||1.01|0.47|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.01||||1.01|0.51|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.01||||1.01|0.51|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.01||||1.01|0.64|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.01||||1.01|0.3|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1.01||||1.01|0.56|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.01||||1.01|0.7|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.01||||1.01|0.51|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.01||||1.01|0.45|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.01||||1.01|0.3|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.01||||1.01|0.45|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.01||||1.01|0.3|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.01||||1.01|0.3|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.01||||1.01|0.7|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.01||||1.01|0.3|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|1.01||||1.01|0.35|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.01||||1.01|0.3|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.01||||1.01|0.3|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.01||||1.01||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|AARP [1000]|AARP [100000]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|AETNA [1015]|AETNA [101529]|10.08||||10.08|4.45|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.08||||10.08|2.99|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|10.08||||10.08|4.74|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.08||||10.08|5.04|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.08||||10.08|5.04|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.08||||10.08|6.35|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.08||||10.08|2.99|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|10.08||||10.08|5.54|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.08||||10.08|6.96|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.08||||10.08|5.04|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.08||||10.08|4.45|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.08||||10.08|2.99|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.08||||10.08|4.45|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.08||||10.08|2.99|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.08||||10.08|2.99|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.08||||10.08|6.96|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.08||||10.08|2.99|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|Self-pay|Self-pay|10.08||||10.08|3.53|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.08||||10.08|2.99|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.08||||10.08|2.99|6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.08||||10.08||6.96|0.3
25246|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.08||||10.08||6.96|0.3
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.68||||3.68|1.62|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.68||||3.68|1.09|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.68||||3.68|1.73|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.68||||3.68|1.84|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.68||||3.68|1.84|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.68||||3.68|2.32|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.68||||3.68|1.09|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.68||||3.68|2.02|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.68||||3.68|2.54|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.68||||3.68|1.84|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.68||||3.68|1.62|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.68||||3.68|1.09|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.68||||3.68|1.62|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.68||||3.68|1.09|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.68||||3.68|1.09|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.68||||3.68|2.54|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.68||||3.68|1.09|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|Self-pay|Self-pay|3.68||||3.68|1.29|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.68||||3.68|1.09|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.68||||3.68|1.09|2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.68||||3.68||2.54|1.09
2528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIPYRIDAMOLE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.68||||3.68||2.54|1.09
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.04||||1.04|0.46|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.04||||1.04|0.31|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.04||||1.04|0.49|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.04||||1.04|0.52|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.04||||1.04|0.52|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.04||||1.04|0.66|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.04||||1.04|0.31|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.04||||1.04|0.57|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.04||||1.04|0.72|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.04||||1.04|0.52|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.04||||1.04|0.46|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.04||||1.04|0.31|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.04||||1.04|0.46|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.04||||1.04|0.31|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.04||||1.04|0.31|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.04||||1.04|0.72|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.04||||1.04|0.31|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|Self-pay|Self-pay|1.04||||1.04|0.36|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.04||||1.04|0.31|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.04||||1.04|0.31|0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.04||||1.04||0.72|0.31
25425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FEXOFENADINE 180 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.04||||1.04||0.72|0.31
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.52||||0.52|0.23|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.52||||0.52|0.15|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.52||||0.52|0.24|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.52||||0.52|0.26|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.52||||0.52|0.26|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.52||||0.52|0.33|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.52||||0.52|0.15|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.52||||0.52|0.29|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.52||||0.52|0.36|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.52||||0.52|0.26|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.52||||0.52|0.23|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.52||||0.52|0.15|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.52||||0.52|0.23|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.52||||0.52|0.15|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.52||||0.52|0.15|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.52||||0.52|0.36|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.52||||0.52|0.15|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|Self-pay|Self-pay|0.52||||0.52|0.18|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.52||||0.52|0.15|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.52||||0.52|0.15|0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.52||||0.52||0.36|0.15
25519|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.52||||0.52||0.36|0.15
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|0.7||||0.7|0.31|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.7||||0.7|0.21|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.7||||0.7|0.33|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.7||||0.7|0.35|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.7||||0.7|0.35|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.7||||0.7|0.44|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.7||||0.7|0.21|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.7||||0.7|0.39|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.7||||0.7|0.48|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.7||||0.7|0.35|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.7||||0.7|0.31|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.7||||0.7|0.21|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.7||||0.7|0.31|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.7||||0.7|0.21|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.7||||0.7|0.21|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.7||||0.7|0.48|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.7||||0.7|0.21|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|0.7||||0.7|0.24|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.7||||0.7|0.21|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.7||||0.7|0.21|0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.7||||0.7||0.48|0.21
2552|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 250 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.7||||0.7||0.48|0.21
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.85||||0.85|0.37|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.85||||0.85|0.25|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.85||||0.85|0.4|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.85||||0.85|0.43|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.85||||0.85|0.43|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.85||||0.85|0.54|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.85||||0.85|0.25|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.85||||0.85|0.47|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.85||||0.85|0.59|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.85||||0.85|0.43|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.85||||0.85|0.37|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.85||||0.85|0.25|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.85||||0.85|0.37|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.85||||0.85|0.25|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.85||||0.85|0.25|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.85||||0.85|0.59|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.85||||0.85|0.25|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.85||||0.85|0.3|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.85||||0.85|0.25|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.85||||0.85|0.25|0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.85||||0.85||0.59|0.25
25520|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.85||||0.85||0.59|0.25
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.42||||0.42|0.19|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.42||||0.42|0.12|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.42||||0.42|0.2|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.42||||0.42|0.21|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.42||||0.42|0.21|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.42||||0.42|0.26|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.42||||0.42|0.12|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.42||||0.42|0.23|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.42||||0.42|0.29|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.42||||0.42|0.21|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.42||||0.42|0.19|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.42||||0.42|0.12|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.42||||0.42|0.19|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.42||||0.42|0.12|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.42||||0.42|0.12|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.42||||0.42|0.29|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.42||||0.42|0.12|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|Self-pay|Self-pay|0.42||||0.42|0.15|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.42||||0.42|0.12|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.42||||0.42|0.12|0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.42||||0.42||0.29|0.12
25528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.42||||0.42||0.29|0.12
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.57||||0.57|0.25|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.57||||0.57|0.17|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.57||||0.57|0.27|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.57||||0.57|0.29|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.57||||0.57|0.29|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.57||||0.57|0.36|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.57||||0.57|0.17|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.57||||0.57|0.31|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.57||||0.57|0.39|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.57||||0.57|0.29|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.57||||0.57|0.25|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.57||||0.57|0.17|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.57||||0.57|0.25|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.57||||0.57|0.17|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.57||||0.57|0.17|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.57||||0.57|0.39|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.57||||0.57|0.17|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|Self-pay|Self-pay|0.57||||0.57|0.2|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.57||||0.57|0.17|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.57||||0.57|0.17|0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.57||||0.57||0.39|0.17
25529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PIOGLITAZONE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.57||||0.57||0.39|0.17
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.11||||1.11|0.49|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.11||||1.11|0.33|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.11||||1.11|0.52|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.11||||1.11|0.56|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.11||||1.11|0.56|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.11||||1.11|0.7|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.11||||1.11|0.33|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.11||||1.11|0.61|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.11||||1.11|0.77|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.11||||1.11|0.56|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.11||||1.11|0.49|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.11||||1.11|0.33|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.11||||1.11|0.49|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.11||||1.11|0.33|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.11||||1.11|0.33|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.11||||1.11|0.77|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.11||||1.11|0.33|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|1.11||||1.11|0.39|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.11||||1.11|0.33|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.11||||1.11|0.33|0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.11||||1.11||0.77|0.33
2553|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 500 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.11||||1.11||0.77|0.33
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.42||||0.42|0.19|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.42||||0.42|0.12|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.42||||0.42|0.2|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.42||||0.42|0.21|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.42||||0.42|0.21|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.42||||0.42|0.26|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.42||||0.42|0.12|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.42||||0.42|0.23|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.42||||0.42|0.29|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.42||||0.42|0.21|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.42||||0.42|0.19|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.42||||0.42|0.12|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.42||||0.42|0.19|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.42||||0.42|0.12|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.42||||0.42|0.12|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.42||||0.42|0.29|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.42||||0.42|0.12|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.42||||0.42|0.15|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.42||||0.42|0.12|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.42||||0.42|0.12|0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.42||||0.42||0.29|0.12
2566|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOCUSATE SODIUM 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.42||||0.42||0.29|0.12
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.84||||12.84|5.66|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.84||||12.84|3.81|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|12.84||||12.84|6.03|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.84||||12.84|6.42|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.84||||12.84|6.42|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.84||||12.84|8.09|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.84||||12.84|3.81|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|12.84||||12.84|7.06|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.84||||12.84|8.86|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.84||||12.84|6.42|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.84||||12.84|5.66|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.84||||12.84|3.81|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.84||||12.84|5.66|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.84||||12.84|3.81|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.84||||12.84|3.81|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.84||||12.84|8.86|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.84||||12.84|3.81|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|Self-pay|Self-pay|12.84||||12.84|4.49|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.84||||12.84|3.81|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.84||||12.84|3.81|8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.84||||12.84||8.86|3.81
25820|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IVERMECTIN 3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.84||||12.84||8.86|3.81
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|9.07||||9.07|8.16|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.07||||9.07|2.69|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|9.07||||9.07|4.26|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.07||||9.07|0|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.07||||9.07|4.54|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.07||||9.07|5.71|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.07||||9.07|2.69|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|9.07||||9.07|4.99|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.07||||9.07|6.26|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.07||||9.07|0.83|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.07||||9.07|8.16|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.07||||9.07|2.69|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.07||||9.07|8.16|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.07||||9.07|2.69|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.07||||9.07|2.69|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.07||||9.07|6.26|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.07||||9.07|2.69|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|9.07||||9.07|3.17|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.07||||9.07|2.69|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.07||||9.07|2.45|8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.07||||9.07||8.16|0.83
2595|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOPAMINE 200 MG/5 ML (40 MG/ML) INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.07||||9.07||8.16|0.83
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|AARP [1000]|AARP [100000]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|AETNA [1015]|AETNA [101529]|845||||845|372.65|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|845||||845|250.54|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|BCBS [1155]|BCBS UTHCT [115568]|845||||845|397.15|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|845||||845|377.71|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|845||||845|422.5|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|845||||845|532.35|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|845||||845|250.54|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|CIGNA [1260]|CIGNA GWH [126023]|845||||845|464.75|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|845||||845|583.05|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|845||||845|388.44|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|845||||845|372.65|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|845||||845|250.54|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|845||||845|372.65|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|845||||845|250.54|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|845||||845|250.54|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|845||||845|583.05|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|845||||845|250.54|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|Self-pay|Self-pay|845||||845|295.75|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|845||||845|250.54|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|845||||845|250.54|583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|845||||845||583.05|250.54
26000243|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION/SUBQ INJ CASIRIVIMAB/IMDEVIMAB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|AARP [1000]|AARP [100000]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|AETNA [1015]|AETNA [101529]|845||||845|372.65|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|845||||845|250.54|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|BCBS [1155]|BCBS UTHCT [115568]|845||||845|397.15|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|845||||845|422.5|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|845||||845|422.5|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|845||||845|532.35|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|845||||845|250.54|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|CIGNA [1260]|CIGNA GWH [126023]|845||||845|464.75|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|845||||845|583.05|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|845||||845|422.5|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|845||||845|372.65|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|845||||845|250.54|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|845||||845|372.65|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|845||||845|250.54|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|845||||845|250.54|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|845||||845|583.05|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|845||||845|250.54|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|Self-pay|Self-pay|845||||845|295.75|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|845||||845|250.54|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|845||||845|250.54|583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|845||||845||583.05|250.54
26000245|EAP|0260 - IV THERAPY-GENERAL|HC IV INFUSION BAMLAN AND ETESEV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|845||||845||583.05|250.54
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.66||||1.66|0.73|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.66||||1.66|0.49|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.66||||1.66|0.78|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.66||||1.66|0.83|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.66||||1.66|0.83|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.66||||1.66|1.05|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.66||||1.66|0.49|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.66||||1.66|0.91|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.66||||1.66|1.15|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.66||||1.66|0.83|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.66||||1.66|0.73|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.66||||1.66|0.49|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.66||||1.66|0.73|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.66||||1.66|0.49|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.66||||1.66|0.49|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.66||||1.66|1.15|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.66||||1.66|0.49|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.66||||1.66|0.58|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.66||||1.66|0.49|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.66||||1.66|0.49|1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.66||||1.66||1.15|0.49
2608|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.66||||1.66||1.15|0.49
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|AARP [1000]|AARP [100000]|114||||114|51.3|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|114||||114|186.38|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|AETNA [1015]|AETNA [101529]|114||||114|50.27|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|114||||114|33.8|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|114||||114|184.54|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|114||||114|184.54|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|114||||114|53.58|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|114||||114|57.79|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|114||||114|57|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|114||||114|71.82|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|114||||114|33.8|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|114||||114|184.54|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|114||||114|62.7|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|114||||114|78.66|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|114||||114|254.38|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|114||||114|197.64|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|114||||114|50.27|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|114||||114|33.8|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|114||||114|184.54|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|114||||114|50.27|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|114||||114|33.8|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|114||||114|33.8|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|114||||114|78.66|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|114||||114|33.8|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|Self-pay|Self-pay|114||||114|39.9|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|114||||114|33.8|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|114||||114|33.8|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|114||||114|51.3|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|114||||114|184.54|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|114||||114|184.54|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|114||||114|51.3|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|114||||114|184.54|369.07|33.8
26096360|EAP|0260 - IV THERAPY-GENERAL|HC IV HYDRATION INITIAL 31-60 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|114||||114|369.07|369.07|33.8
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AARP [1000]|AARP [100000]|345||||345|155.25|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|345||||345|36.63|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AETNA [1015]|AETNA [101529]|345||||345|152.15|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|345||||345|102.29|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|345||||345|36.27|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|345||||345|36.27|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS [1155]|BCBS UTHCT [115568]|345||||345|162.15|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|345||||345|17.08|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|345||||345|172.5|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|345||||345|217.35|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|345||||345|102.29|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|345||||345|36.27|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|CIGNA [1260]|CIGNA GWH [126023]|345||||345|189.75|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|345||||345|238.05|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|345||||345|50|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|345||||345|38.85|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|345||||345|152.15|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|345||||345|102.29|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|345||||345|36.27|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|345||||345|152.15|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|345||||345|102.29|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|345||||345|102.29|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|345||||345|238.05|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|345||||345|102.29|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|Self-pay|Self-pay|345||||345|120.75|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|345||||345|102.29|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|345||||345|102.29|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|345||||345|155.25|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|345||||345|36.27|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|345||||345|36.27|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|345||||345|155.25|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|345||||345|36.27|238.05|17.08
26096361|EAP|0260 - IV THERAPY-GENERAL|HC IV INF HYDRATION EACH ADDL HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|345||||345|72.54|238.05|17.08
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|AARP [1000]|AARP [100000]|569||||569|256.05|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|569||||569|186.38|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|AETNA [1015]|AETNA [101529]|569||||569|250.93|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|569||||569|168.71|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|569||||569|184.54|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|569||||569|184.54|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|BCBS [1155]|BCBS UTHCT [115568]|569||||569|267.43|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|569||||569|90.19|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|569||||569|284.5|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|569||||569|358.47|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|569||||569|168.71|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|569||||569|184.54|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|CIGNA [1260]|CIGNA GWH [126023]|569||||569|312.95|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|569||||569|392.61|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|569||||569|254.38|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|569||||569|197.64|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|569||||569|250.93|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|569||||569|168.71|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|569||||569|184.54|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|569||||569|250.93|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|569||||569|168.71|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|569||||569|168.71|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|569||||569|392.61|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|569||||569|168.71|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|Self-pay|Self-pay|569||||569|199.15|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|569||||569|168.71|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|569||||569|168.71|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|569||||569|256.05|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|569||||569|184.54|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|569||||569|184.54|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|569||||569|256.05|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|569||||569|184.54|392.61|90.19
26096365|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX INITIAL 1ST HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|569||||569|369.07|392.61|90.19
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|AARP [1000]|AARP [100000]|103||||103|46.35|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|103||||103|36.63|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|AETNA [1015]|AETNA [101529]|103||||103|45.42|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|103||||103|30.54|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|103||||103|36.27|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|103||||103|36.27|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|BCBS [1155]|BCBS UTHCT [115568]|103||||103|48.41|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|103||||103|27.15|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|103||||103|51.5|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|103||||103|64.89|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|103||||103|30.54|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|103||||103|36.27|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|CIGNA [1260]|CIGNA GWH [126023]|103||||103|56.65|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|103||||103|71.07|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|103||||103|50|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|103||||103|38.85|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|103||||103|45.42|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|103||||103|30.54|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|103||||103|36.27|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|103||||103|45.42|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|103||||103|30.54|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|103||||103|30.54|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|103||||103|71.07|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|103||||103|30.54|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|Self-pay|Self-pay|103||||103|36.05|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|103||||103|30.54|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|103||||103|30.54|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|103||||103|46.35|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|103||||103|36.27|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|103||||103|36.27|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|103||||103|46.35|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|103||||103|36.27|72.54|27.15
26096366|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX EACH ADDL HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|103||||103|72.54|72.54|27.15
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|AARP [1000]|AARP [100000]|181||||181|81.45|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181||||181|56.76|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|AETNA [1015]|AETNA [101529]|181||||181|79.82|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181||||181|53.67|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181||||181|56.2|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181||||181|56.2|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|BCBS [1155]|BCBS UTHCT [115568]|181||||181|85.07|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181||||181|38.97|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181||||181|90.5|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181||||181|114.03|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181||||181|53.67|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181||||181|56.2|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|CIGNA [1260]|CIGNA GWH [126023]|181||||181|99.55|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|181||||181|124.89|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|181||||181|77.46|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181||||181|60.19|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181||||181|79.82|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181||||181|53.67|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181||||181|56.2|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181||||181|79.82|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181||||181|53.67|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|181||||181|53.67|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|181||||181|124.89|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181||||181|53.67|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|Self-pay|Self-pay|181||||181|63.35|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|181||||181|53.67|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181||||181|53.67|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181||||181|81.45|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|181||||181|56.2|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|181||||181|56.2|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181||||181|81.45|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181||||181|56.2|124.89|38.97
26096367|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX ADD DIFF DRUG UP TO 1HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181||||181|112.4|124.89|38.97
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|AARP [1000]|AARP [100000]|70||||70|31.5|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70||||70||48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|AETNA [1015]|AETNA [101529]|70||||70|30.87|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70||||70|20.76|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70||||70||48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70||||70||48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|BCBS [1155]|BCBS UTHCT [115568]|70||||70|32.9|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70||||70|25.83|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70||||70|35|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70||||70|44.1|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70||||70|20.76|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70||||70||48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|CIGNA [1260]|CIGNA GWH [126023]|70||||70|38.5|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70||||70|48.3|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70||||70|35|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70||||70||48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70||||70|30.87|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70||||70|20.76|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70||||70||48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70||||70|30.87|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70||||70|20.76|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70||||70|20.76|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70||||70|48.3|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70||||70|20.76|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|Self-pay|Self-pay|70||||70|24.5|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70||||70|20.76|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70||||70|20.76|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70||||70|31.5|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70||||70||48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70||||70||48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70||||70|31.5|48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70||||70||48.3|20.76
26096368|EAP|0260 - IV THERAPY-GENERAL|HC IV INF TX/DX CONCURRENT DRUGS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70||||70||48.3|20.76
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|AARP [1000]|AARP [100000]|181.41||||181.41|81.63|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181.41||||181.41|56.76|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|AETNA [1015]|AETNA [101529]|181.41||||181.41|80|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181.41||||181.41|53.79|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181.41||||181.41|56.2|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181.41||||181.41|56.2|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|BCBS [1155]|BCBS UTHCT [115568]|181.41||||181.41|85.26|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181.41||||181.41|71|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181.41||||181.41|90.71|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181.41||||181.41|114.29|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181.41||||181.41|53.79|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181.41||||181.41|56.2|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|CIGNA [1260]|CIGNA GWH [126023]|181.41||||181.41|99.78|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|181.41||||181.41|125.17|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|181.41||||181.41|77.46|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181.41||||181.41|60.19|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181.41||||181.41|80|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181.41||||181.41|53.79|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181.41||||181.41|56.2|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181.41||||181.41|80|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181.41||||181.41|53.79|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|181.41||||181.41|53.79|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|181.41||||181.41|125.17|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181.41||||181.41|53.79|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|Self-pay|Self-pay|181.41||||181.41|63.49|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|181.41||||181.41|53.79|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181.41||||181.41|53.79|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181.41||||181.41|81.63|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|181.41||||181.41|56.2|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|181.41||||181.41|56.2|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181.41||||181.41|81.63|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181.41||||181.41|56.2|125.17|53.79
26096372|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IM/SQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181.41||||181.41|112.4|125.17|53.79
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|AARP [1000]|AARP [100000]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|AETNA [1015]|AETNA [101529]|669.83||||669.83|295.4|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|669.83||||669.83|198.6|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|BCBS [1155]|BCBS UTHCT [115568]|669.83||||669.83|314.82|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|669.83||||669.83|23.64|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|669.83||||669.83|334.92|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|669.83||||669.83|421.99|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|669.83||||669.83|198.6|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|CIGNA [1260]|CIGNA GWH [126023]|669.83||||669.83|368.41|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|669.83||||669.83|462.18|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|669.83||||669.83|254.38|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|669.83||||669.83|295.4|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|669.83||||669.83|198.6|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|669.83||||669.83|295.4|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|669.83||||669.83|198.6|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|669.83||||669.83|198.6|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|669.83||||669.83|462.18|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|669.83||||669.83|198.6|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|Self-pay|Self-pay|669.83||||669.83|234.44|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|669.83||||669.83|198.6|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|669.83||||669.83|198.6|462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|669.83||||669.83||462.18|23.64
26096373|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX INTRA-ART PUSH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|669.83||||669.83||462.18|23.64
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|AARP [1000]|AARP [100000]|551||||551|247.95|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|551||||551|186.38|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|AETNA [1015]|AETNA [101529]|551||||551|242.99|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|551||||551|163.37|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|551||||551|184.54|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|551||||551|184.54|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|BCBS [1155]|BCBS UTHCT [115568]|551||||551|258.97|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|551||||551|57.35|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|551||||551|275.5|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|551||||551|347.13|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|551||||551|163.37|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|551||||551|184.54|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|CIGNA [1260]|CIGNA GWH [126023]|551||||551|303.05|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|551||||551|380.19|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|551||||551|254.38|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|551||||551|197.64|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|551||||551|242.99|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|551||||551|163.37|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|551||||551|184.54|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|551||||551|242.99|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|551||||551|163.37|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|551||||551|163.37|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|551||||551|380.19|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|551||||551|163.37|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|Self-pay|Self-pay|551||||551|192.85|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|551||||551|163.37|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|551||||551|163.37|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|551||||551|247.95|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|551||||551|184.54|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|551||||551|184.54|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|551||||551|247.95|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|551||||551|184.54|380.19|57.35
26096374|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IV PUSH SGL OR INI DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|551||||551|369.07|380.19|57.35
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AARP [1000]|AARP [100000]|114||||114|51.3|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|114||||114|36.63|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AETNA [1015]|AETNA [101529]|114||||114|50.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|114||||114|33.8|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|114||||114|36.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|114||||114|36.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS [1155]|BCBS UTHCT [115568]|114||||114|53.58|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|114||||114|22.33|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|114||||114|57|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|114||||114|71.82|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|114||||114|33.8|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|114||||114|36.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|CIGNA [1260]|CIGNA GWH [126023]|114||||114|62.7|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|114||||114|78.66|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|114||||114|50|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|114||||114|38.85|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|114||||114|50.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|114||||114|33.8|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|114||||114|36.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|114||||114|50.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|114||||114|33.8|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|114||||114|33.8|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|114||||114|78.66|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|114||||114|33.8|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|Self-pay|Self-pay|114||||114|39.9|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|114||||114|33.8|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|114||||114|33.8|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|114||||114|51.3|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|114||||114|36.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|114||||114|36.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|114||||114|51.3|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|114||||114|36.27|78.66|22.33
26096375|EAP|0260 - IV THERAPY-GENERAL|HC IV PUSH EA ADD SEQ/DIFF DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|114||||114|72.54|78.66|22.33
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|AARP [1000]|AARP [100000]|237||||237|106.65|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237||||237||163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|AETNA [1015]|AETNA [101529]|237||||237|104.52|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237||||237|70.27|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237||||237||163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237||||237||163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|BCBS [1155]|BCBS UTHCT [115568]|237||||237|111.39|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237||||237|28.02|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237||||237|118.5|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237||||237|149.31|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237||||237|70.27|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237||||237||163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|CIGNA [1260]|CIGNA GWH [126023]|237||||237|130.35|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|237||||237|163.53|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|237||||237|118.5|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237||||237||163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237||||237|104.52|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237||||237|70.27|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237||||237||163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237||||237|104.52|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237||||237|70.27|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|237||||237|70.27|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|237||||237|163.53|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237||||237|70.27|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|Self-pay|Self-pay|237||||237|82.95|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|237||||237|70.27|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237||||237|70.27|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237||||237|106.65|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|237||||237||163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|237||||237||163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237||||237|106.65|163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237||||237||163.53|28.02
26096376|EAP|0260 - IV THERAPY-GENERAL|HC INJ TX/DX IVP EA ADDL SAME DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237||||237||163.53|28.02
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|AARP [1000]|AARP [100000]|135.56||||135.56|61|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135.56||||135.56|36.63|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|AETNA [1015]|AETNA [101529]|135.56||||135.56|59.78|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135.56||||135.56|40.19|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135.56||||135.56|36.27|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135.56||||135.56|36.27|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|BCBS [1155]|BCBS UTHCT [115568]|135.56||||135.56|63.71|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135.56||||135.56|45.18|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135.56||||135.56|67.78|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135.56||||135.56|85.4|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135.56||||135.56|40.19|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135.56||||135.56|36.27|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|CIGNA [1260]|CIGNA GWH [126023]|135.56||||135.56|74.56|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|135.56||||135.56|93.54|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|135.56||||135.56|50|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135.56||||135.56|38.85|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135.56||||135.56|59.78|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135.56||||135.56|40.19|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135.56||||135.56|36.27|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135.56||||135.56|59.78|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135.56||||135.56|40.19|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|135.56||||135.56|40.19|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|135.56||||135.56|93.54|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135.56||||135.56|40.19|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|Self-pay|Self-pay|135.56||||135.56|47.45|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|135.56||||135.56|40.19|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135.56||||135.56|40.19|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135.56||||135.56|61|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|135.56||||135.56|36.27|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|135.56||||135.56|36.27|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135.56||||135.56|61|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135.56||||135.56|36.27|93.54|36.27
26096377|EAP|0260 - IV THERAPY-GENERAL|HC APPLY ON-BODY INJECTOR FOR SQ INJ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135.56||||135.56|72.54|93.54|36.27
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.18||||2.18|0.96|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.18||||2.18|0.65|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|2.18||||2.18|1.02|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.18||||2.18|1.09|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.18||||2.18|1.09|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.18||||2.18|1.37|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.18||||2.18|0.65|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|2.18||||2.18|1.2|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.18||||2.18|1.5|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.18||||2.18|1.09|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.18||||2.18|0.96|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.18||||2.18|0.65|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.18||||2.18|0.96|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.18||||2.18|0.65|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.18||||2.18|0.65|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.18||||2.18|1.5|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.18||||2.18|0.65|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.18||||2.18|0.76|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.18||||2.18|0.65|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.18||||2.18|0.65|1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.18||||2.18||1.5|0.65
2611|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXEPIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.18||||2.18||1.5|0.65
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|413.23||||413.23|258|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|413.23||||413.23||285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|413.23||||413.23|140.64|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|413.23||||413.23|122.52|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|413.23||||413.23||285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|413.23||||413.23||285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|413.23||||413.23|194.22|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|413.23||||413.23|0|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|413.23||||413.23|206.62|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|413.23||||413.23|260.33|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|413.23||||413.23|122.52|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|413.23||||413.23||285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|413.23||||413.23|227.28|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|413.23||||413.23|285.13|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|413.23||||413.23|3.13|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|413.23||||413.23||285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|413.23||||413.23|140.64|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|413.23||||413.23|122.52|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|413.23||||413.23||285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|413.23||||413.23|140.64|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|413.23||||413.23|122.52|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|413.23||||413.23|122.52|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|413.23||||413.23|285.13|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|413.23||||413.23|122.52|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|413.23||||413.23|144.63|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|413.23||||413.23|122.52|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|413.23||||413.23|122.52|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|413.23||||413.23|258|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|413.23||||413.23||285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|413.23||||413.23||285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|413.23||||413.23|258|285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|413.23||||413.23||285.13|3.13
2616|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 2 MG/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|413.23||||413.23||285.13|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|AARP [1000]|AARP [100000]|815.4||||815.4|64.5|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|815.4||||815.4||562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA [1015]|AETNA [101529]|815.4||||815.4|35.16|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|815.4||||815.4|241.77|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|815.4||||815.4||562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|815.4||||815.4||562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BCBS UTHCT [115568]|815.4||||815.4|383.24|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|815.4||||815.4|0|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|815.4||||815.4|407.7|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|815.4||||815.4|513.7|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|815.4||||815.4|241.77|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|815.4||||815.4||562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA GWH [126023]|815.4||||815.4|407.7|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|815.4||||815.4|562.63|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|815.4||||815.4|3.13|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|815.4||||815.4||562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|815.4||||815.4|35.16|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|815.4||||815.4|241.77|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|815.4||||815.4||562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|815.4||||815.4|35.16|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|815.4||||815.4|241.77|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|815.4||||815.4|241.77|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|815.4||||815.4|562.63|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|815.4||||815.4|241.77|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|Self-pay|Self-pay|815.4||||815.4|285.39|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|815.4||||815.4|241.77|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|815.4||||815.4|241.77|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|815.4||||815.4|64.5|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|815.4||||815.4||562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|815.4||||815.4||562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|815.4||||815.4|64.5|562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|815.4||||815.4||562.63|3.13
2619|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|815.4||||815.4||562.63|3.13
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|AARP [1000]|AARP [100000]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|AETNA [1015]|AETNA [101529]|16.47||||16.47|7.26|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.47||||16.47|4.88|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|16.47||||16.47|7.74|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.47||||16.47|8.24|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.47||||16.47|8.24|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.47||||16.47|10.38|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.47||||16.47|4.88|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|16.47||||16.47|9.06|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.47||||16.47|11.36|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.47||||16.47|8.24|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.47||||16.47|7.26|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.47||||16.47|4.88|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.47||||16.47|7.26|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.47||||16.47|4.88|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.47||||16.47|4.88|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.47||||16.47|11.36|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.47||||16.47|4.88|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|Self-pay|Self-pay|16.47||||16.47|5.76|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.47||||16.47|4.88|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.47||||16.47|4.88|11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.47||||16.47||11.36|4.88
2621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE 50 MG/5 ML ORAL SYRUP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.47||||16.47||11.36|4.88
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AARP [1000]|AARP [100000]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|65.29||||65.29|28.79|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65.29||||65.29|19.36|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|65.29||||65.29|30.69|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65.29||||65.29|32.65|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65.29||||65.29|32.65|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65.29||||65.29|41.13|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65.29||||65.29|19.36|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|65.29||||65.29|35.91|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|65.29||||65.29|45.05|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65.29||||65.29|32.65|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65.29||||65.29|28.79|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65.29||||65.29|19.36|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65.29||||65.29|28.79|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65.29||||65.29|19.36|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|65.29||||65.29|19.36|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|65.29||||65.29|45.05|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65.29||||65.29|19.36|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|Self-pay|Self-pay|65.29||||65.29|22.85|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65.29||||65.29|19.36|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65.29||||65.29|19.36|45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65.29||||65.29||45.05|19.36
2622|ERX|0250 - PHARMACY-GENERAL|DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65.29||||65.29||45.05|19.36
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.17||||1.17|0.52|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.17||||1.17|0.35|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.17||||1.17|0.55|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.17||||1.17|0.59|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.17||||1.17|0.59|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.17||||1.17|0.74|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.17||||1.17|0.35|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.17||||1.17|0.64|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.17||||1.17|0.81|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.17||||1.17|0.59|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.17||||1.17|0.52|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.17||||1.17|0.35|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.17||||1.17|0.52|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.17||||1.17|0.35|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.17||||1.17|0.35|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.17||||1.17|0.81|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.17||||1.17|0.35|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|1.17||||1.17|0.41|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.17||||1.17|0.35|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.17||||1.17|0.35|0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.17||||1.17||0.81|0.35
26225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PANTOPRAZOLE 40 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.17||||1.17||0.81|0.35
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AARP [1000]|AARP [100000]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AETNA [1015]|AETNA [101529]|15.5||||15.5|11.52|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|7.75|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|7.75|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|11.52|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|11.52|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|Self-pay|Self-pay|15.5||||15.5|5.42|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||11.52|4.6
26226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PANTOPRAZOLE 40 MG INTRAVENOUS SOLUTION|40 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||11.52|4.6
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|11.89||||11.89|5.24|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.89||||11.89|3.53|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|11.89||||11.89|5.59|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.89||||11.89|5.95|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.89||||11.89|5.95|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.89||||11.89|7.49|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.89||||11.89|3.53|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|11.89||||11.89|6.54|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|11.89||||11.89|8.2|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.89||||11.89|5.95|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.89||||11.89|5.24|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.89||||11.89|3.53|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.89||||11.89|5.24|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.89||||11.89|3.53|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.89||||11.89|3.53|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|11.89||||11.89|8.2|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.89||||11.89|3.53|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|Self-pay|Self-pay|11.89||||11.89|4.16|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.89||||11.89|3.53|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.89||||11.89|3.53|8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.89||||11.89||8.2|3.53
2625|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXYCYCLINE HYCLATE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.89||||11.89||8.2|3.53
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|2.26||||2.26|1|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.26||||2.26|0.67|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.26||||2.26|1.06|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.26||||2.26|1.13|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.26||||2.26|1.13|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.26||||2.26|1.42|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.26||||2.26|0.67|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.26||||2.26|1.24|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.26||||2.26|1.56|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.26||||2.26|1.13|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.26||||2.26|1|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.26||||2.26|0.67|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.26||||2.26|1|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.26||||2.26|0.67|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.26||||2.26|0.67|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.26||||2.26|1.56|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.26||||2.26|0.67|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|2.26||||2.26|0.79|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.26||||2.26|0.67|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.26||||2.26|0.67|1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.26||||2.26||1.56|0.67
26371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA ER 50 MG-LEVODOPA 200 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.26||||2.26||1.56|0.67
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|26.89||||26.89|11.86|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.89||||26.89|7.97|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|26.89||||26.89|12.64|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.89||||26.89|13.45|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.89||||26.89|13.45|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.89||||26.89|16.94|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.89||||26.89|7.97|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|26.89||||26.89|14.79|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|26.89||||26.89|18.55|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|26.89||||26.89|13.45|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.89||||26.89|11.86|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.89||||26.89|7.97|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.89||||26.89|11.86|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.89||||26.89|7.97|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|26.89||||26.89|7.97|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|26.89||||26.89|18.55|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.89||||26.89|7.97|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|Self-pay|Self-pay|26.89||||26.89|9.41|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|26.89||||26.89|7.97|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.89||||26.89|7.97|18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.89||||26.89||18.55|7.97
26546|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OSELTAMIVIR 75 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.89||||26.89||18.55|7.97
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.8||||9.8|4.32|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.8||||9.8|2.91|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|9.8||||9.8|4.61|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.8||||9.8|4.9|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.8||||9.8|4.9|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.8||||9.8|6.17|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.8||||9.8|2.91|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|9.8||||9.8|5.39|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.8||||9.8|6.76|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.8||||9.8|4.9|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.8||||9.8|4.32|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.8||||9.8|2.91|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.8||||9.8|4.32|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.8||||9.8|2.91|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.8||||9.8|2.91|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.8||||9.8|6.76|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.8||||9.8|2.91|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|Self-pay|Self-pay|9.8||||9.8|3.43|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.8||||9.8|2.91|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.8||||9.8|2.91|6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.8||||9.8||6.76|2.91
26547|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENTACAPONE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.8||||9.8||6.76|2.91
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.78||||0.78|0.34|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.78||||0.78|0.23|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.78||||0.78|0.37|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.78||||0.78|0.39|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.78||||0.78|0.39|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.78||||0.78|0.49|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.78||||0.78|0.23|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.78||||0.78|0.43|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.78||||0.78|0.54|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.78||||0.78|0.39|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.78||||0.78|0.34|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.78||||0.78|0.23|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.78||||0.78|0.34|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.78||||0.78|0.23|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.78||||0.78|0.23|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.78||||0.78|0.54|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.78||||0.78|0.23|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|Self-pay|Self-pay|0.78||||0.78|0.27|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.78||||0.78|0.23|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.78||||0.78|0.23|0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.78||||0.78||0.54|0.23
26816|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.78||||0.78||0.54|0.23
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.9||||1.9|0.84|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.9||||1.9|0.56|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.9||||1.9|0.89|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.9||||1.9|0.95|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.9||||1.9|0.95|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.9||||1.9|1.2|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.9||||1.9|0.56|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.9||||1.9|1.05|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.9||||1.9|1.31|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.9||||1.9|0.95|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.9||||1.9|0.84|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.9||||1.9|0.56|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.9||||1.9|0.84|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.9||||1.9|0.56|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.9||||1.9|0.56|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.9||||1.9|1.31|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.9||||1.9|0.56|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|Self-pay|Self-pay|1.9||||1.9|0.66|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.9||||1.9|0.56|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.9||||1.9|0.56|1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.9||||1.9||1.31|0.56
26952|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.9||||1.9||1.31|0.56
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|32.38||||32.38|14.28|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32.38||||32.38|9.6|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|32.38||||32.38|15.22|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32.38||||32.38|16.19|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32.38||||32.38|16.19|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32.38||||32.38|20.4|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32.38||||32.38|9.6|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|32.38||||32.38|17.81|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|32.38||||32.38|22.34|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|32.38||||32.38|16.19|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32.38||||32.38|14.28|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32.38||||32.38|9.6|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32.38||||32.38|14.28|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32.38||||32.38|9.6|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|32.38||||32.38|9.6|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|32.38||||32.38|22.34|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32.38||||32.38|9.6|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|Self-pay|Self-pay|32.38||||32.38|11.33|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|32.38||||32.38|9.6|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32.38||||32.38|9.6|22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32.38||||32.38||22.34|9.6
26966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOFETILIDE 250 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32.38||||32.38||22.34|9.6
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|AARP [1000]|AARP [100000]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|AETNA [1015]|AETNA [101529]|30||||30|13.23|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30||||30|8.9|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|BCBS [1155]|BCBS UTHCT [115568]|30||||30|14.1|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30||||30|15|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30||||30|15|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30||||30|18.9|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30||||30|8.9|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|CIGNA [1260]|CIGNA GWH [126023]|30||||30|16.5|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|30||||30|20.7|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30||||30|15|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30||||30|13.23|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30||||30|8.9|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30||||30|13.23|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30||||30|8.9|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|30||||30|8.9|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|30||||30|20.7|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30||||30|8.9|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|Self-pay|Self-pay|30||||30|10.5|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30||||30|8.9|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30||||30|8.9|20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30||||30||20.7|8.9
27010033|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC BAG URINE LEG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30||||30||20.7|8.9
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AARP [1000]|AARP [100000]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AETNA [1015]|AETNA [101529]|27||||27|11.91|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27||||27|8.01|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS [1155]|BCBS UTHCT [115568]|27||||27|12.69|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27||||27|13.5|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27||||27|13.5|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27||||27|17.01|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27||||27|8.01|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|CIGNA [1260]|CIGNA GWH [126023]|27||||27|14.85|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|27||||27|18.63|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27||||27|13.5|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27||||27|11.91|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27||||27|8.01|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27||||27|11.91|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27||||27|8.01|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|27||||27|8.01|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|27||||27|18.63|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27||||27|8.01|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|Self-pay|Self-pay|27||||27|9.45|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27||||27|8.01|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27||||27|8.01|18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27||||27||18.63|8.01
27010179|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC EXCHANGER HEAT/MOISTURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27||||27||18.63|8.01
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AARP [1000]|AARP [100000]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AETNA [1015]|AETNA [101529]|504||||504|222.26|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|504||||504|149.44|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BCBS UTHCT [115568]|504||||504|236.88|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|504||||504|252|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|504||||504|252|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|504||||504|317.52|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|504||||504|149.44|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|CIGNA [1260]|CIGNA GWH [126023]|504||||504|277.2|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|504||||504|347.76|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|504||||504|252|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|504||||504|222.26|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|504||||504|149.44|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|504||||504|222.26|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|504||||504|149.44|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|504||||504|149.44|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|504||||504|347.76|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|504||||504|149.44|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|Self-pay|Self-pay|504||||504|176.4|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|504||||504|149.44|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|504||||504|149.44|347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|504||||504||347.76|149.44
27010330|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC OXYGEN/DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|504||||504||347.76|149.44
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|AARP [1000]|AARP [100000]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|AETNA [1015]|AETNA [101529]|305||||305|134.51|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|305||||305|90.43|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|BCBS [1155]|BCBS UTHCT [115568]|305||||305|143.35|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|305||||305|152.5|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|305||||305|152.5|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|305||||305|192.15|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|305||||305|90.43|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|CIGNA [1260]|CIGNA GWH [126023]|305||||305|167.75|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|305||||305|210.45|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|305||||305|152.5|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|305||||305|134.51|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|305||||305|90.43|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|305||||305|134.51|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|305||||305|90.43|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|305||||305|90.43|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|305||||305|210.45|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|305||||305|90.43|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|Self-pay|Self-pay|305||||305|106.75|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|305||||305|90.43|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|305||||305|90.43|210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|305||||305||210.45|90.43
27010388|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|305||||305||210.45|90.43
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|AARP [1000]|AARP [100000]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|AETNA [1015]|AETNA [101529]|24||||24|10.58|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24||||24|7.12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|BCBS [1155]|BCBS UTHCT [115568]|24||||24|11.28|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24||||24|0|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24||||24|12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24||||24|15.12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24||||24|7.12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|CIGNA [1260]|CIGNA GWH [126023]|24||||24|13.2|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|24||||24|16.56|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24||||24|11.28|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24||||24|10.58|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24||||24|7.12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24||||24|10.58|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24||||24|7.12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|24||||24|7.12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|24||||24|16.56|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24||||24|7.12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|Self-pay|Self-pay|24||||24|8.4|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24||||24|7.12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24||||24|7.12|16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24||||24||16.56|7.12
27010406|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC SLING ARM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24||||24||16.56|7.12
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|AARP [1000]|AARP [100000]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|AETNA [1015]|AETNA [101529]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|BCBS [1155]|BCBS UTHCT [115568]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|CIGNA [1260]|CIGNA GWH [126023]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|Self-pay|Self-pay|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0||||0|0||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0||||0|||
27010644|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC AEROBIKA OPEP WITH MANOMETER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0||||0|||
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.68||||1.68|0.74|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.68||||1.68|0.5|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.68||||1.68|0.79|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.68||||1.68|0.84|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.68||||1.68|0.84|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.68||||1.68|1.06|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.68||||1.68|0.5|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.68||||1.68|0.92|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.68||||1.68|1.16|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.68||||1.68|0.84|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.68||||1.68|0.74|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.68||||1.68|0.5|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.68||||1.68|0.74|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.68||||1.68|0.5|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.68||||1.68|0.5|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.68||||1.68|1.16|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.68||||1.68|0.5|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|Self-pay|Self-pay|1.68||||1.68|0.59|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.68||||1.68|0.5|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.68||||1.68|0.5|1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.68||||1.68||1.16|0.5
27049|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.68||||1.68||1.16|0.5
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|1.11||||1.11|0.49|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.11||||1.11|0.33|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.11||||1.11|0.52|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.11||||1.11|0.56|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.11||||1.11|0.56|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.11||||1.11|0.7|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.11||||1.11|0.33|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.11||||1.11|0.61|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.11||||1.11|0.77|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.11||||1.11|0.56|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.11||||1.11|0.49|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.11||||1.11|0.33|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.11||||1.11|0.49|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.11||||1.11|0.33|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.11||||1.11|0.33|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.11||||1.11|0.77|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.11||||1.11|0.33|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|1.11||||1.11|0.39|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.11||||1.11|0.33|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.11||||1.11|0.33|0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.11||||1.11||0.77|0.33
27181|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.11||||1.11||0.77|0.33
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|AARP [1000]|AARP [100000]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|AETNA [1015]|AETNA [101529]|67||||67|29.55|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|67||||67|19.87|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|BCBS [1155]|BCBS UTHCT [115568]|67||||67|31.49|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|67||||67|33.5|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|67||||67|33.5|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|67||||67|42.21|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|67||||67|19.87|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|CIGNA [1260]|CIGNA GWH [126023]|67||||67|36.85|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|67||||67|46.23|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|67||||67|33.5|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|67||||67|29.55|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|67||||67|19.87|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|67||||67|29.55|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|67||||67|19.87|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|67||||67|19.87|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|67||||67|46.23|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|67||||67|19.87|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|Self-pay|Self-pay|67||||67|23.45|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|67||||67|19.87|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|67||||67|19.87|46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|67||||67||46.23|19.87
27210147|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC CATH FOLEY 16FR SILICONE 5CC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|67||||67||46.23|19.87
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AARP [1000]|AARP [100000]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AETNA [1015]|AETNA [101529]|83||||83|36.6|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83||||83|24.61|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|BCBS [1155]|BCBS UTHCT [115568]|83||||83|39.01|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83||||83|41.5|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83||||83|41.5|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83||||83|52.29|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83||||83|24.61|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|CIGNA [1260]|CIGNA GWH [126023]|83||||83|45.65|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|83||||83|57.27|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|83||||83|41.5|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83||||83|36.6|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83||||83|24.61|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83||||83|36.6|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83||||83|24.61|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|83||||83|24.61|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|83||||83|57.27|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83||||83|24.61|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|Self-pay|Self-pay|83||||83|29.05|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|83||||83|24.61|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83||||83|24.61|57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83||||83||57.27|24.61
27210773|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC PEAK FLOW METER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83||||83||57.27|24.61
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AARP [1000]|AARP [100000]|9.45||||9.45|4.25|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.45||||9.45||6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AETNA [1015]|AETNA [101529]|9.45||||9.45|4.17|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.45||||9.45|2.8|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.45||||9.45||6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.45||||9.45||6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BCBS UTHCT [115568]|9.45||||9.45|4.44|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.45||||9.45|0|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.45||||9.45|4.73|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.45||||9.45|5.95|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.45||||9.45|2.8|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.45||||9.45||6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|CIGNA [1260]|CIGNA GWH [126023]|9.45||||9.45|5.2|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9.45||||9.45|6.52|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.45||||9.45|4.73|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.45||||9.45||6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.45||||9.45|4.17|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.45||||9.45|2.8|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.45||||9.45||6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.45||||9.45|4.17|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.45||||9.45|2.8|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.45||||9.45|2.8|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9.45||||9.45|6.52|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.45||||9.45|2.8|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|Self-pay|Self-pay|9.45||||9.45|3.31|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.45||||9.45|2.8|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.45||||9.45|2.8|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.45||||9.45|4.25|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.45||||9.45||6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.45||||9.45||6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.45||||9.45|4.25|6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.45||||9.45||6.52|2.8
27210839|EAP|0270 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-GENER|HC CANNULA NASAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.45||||9.45||6.52|2.8
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|AARP [1000]|AARP [100000]|3140||||3140|1413|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3140||||3140||2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|AETNA [1015]|AETNA [101529]|3140||||3140|1384.74|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3140||||3140|931.01|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3140||||3140||2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3140||||3140||2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|BCBS [1155]|BCBS UTHCT [115568]|3140||||3140|1475.8|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3140||||3140|1570|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3140||||3140|1570|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3140||||3140|1978.2|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3140||||3140|931.01|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3140||||3140||2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|CIGNA [1260]|CIGNA GWH [126023]|3140||||3140|1570|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3140||||3140|2166.6|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3140||||3140|1475.8|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3140||||3140||2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3140||||3140|1384.74|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3140||||3140|931.01|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3140||||3140||2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3140||||3140|1384.74|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3140||||3140|931.01|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3140||||3140|931.01|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3140||||3140|2166.6|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3140||||3140|931.01|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|Self-pay|Self-pay|3140||||3140|1099|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3140||||3140|931.01|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3140||||3140|931.01|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3140||||3140|1413|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3140||||3140||2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3140||||3140||2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3140||||3140|1413|2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3140||||3140||2166.6|931.01
27211515|EAP|0278 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-OTHER|HC TRAY CHEST TUBE INSERTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3140||||3140||2166.6|931.01
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|AARP [1000]|AARP [100000]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|AETNA [1015]|AETNA [101529]|56||||56|24.7|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56||||56|16.6|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|BCBS [1155]|BCBS UTHCT [115568]|56||||56|26.32|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56||||56|28|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56||||56|28|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56||||56|35.28|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56||||56|16.6|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|CIGNA [1260]|CIGNA GWH [126023]|56||||56|30.8|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|56||||56|38.64|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|56||||56|28|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56||||56|24.7|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56||||56|16.6|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56||||56|24.7|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|56||||56|16.6|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|56||||56|16.6|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|56||||56|38.64|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56||||56|16.6|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|Self-pay|Self-pay|56||||56|19.6|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|56||||56|16.6|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56||||56|16.6|38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56||||56||38.64|16.6
27212081|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY DRESSING CHANGE PICC LINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|56||||56||38.64|16.6
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|AARP [1000]|AARP [100000]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|AETNA [1015]|AETNA [101529]|159||||159|70.12|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|159||||159|47.14|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|BCBS [1155]|BCBS UTHCT [115568]|159||||159|74.73|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|159||||159|79.5|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|159||||159|79.5|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|159||||159|100.17|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|159||||159|47.14|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|CIGNA [1260]|CIGNA GWH [126023]|159||||159|87.45|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|159||||159|109.71|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|159||||159|79.5|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|159||||159|70.12|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|159||||159|47.14|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|159||||159|70.12|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|159||||159|47.14|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|159||||159|47.14|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|159||||159|109.71|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|159||||159|47.14|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|Self-pay|Self-pay|159||||159|55.65|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|159||||159|47.14|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|159||||159|47.14|109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|159||||159||109.71|47.14
27212084|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC TRAY FOLEY CATH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|159||||159||109.71|47.14
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AARP [1000]|AARP [100000]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AETNA [1015]|AETNA [101529]|33||||33|14.55|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|9.78|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS [1155]|BCBS UTHCT [115568]|33||||33|15.51|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33||||33|16.5|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33||||33|16.5|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33||||33|20.79|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33||||33|9.78|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|CIGNA [1260]|CIGNA GWH [126023]|33||||33|18.15|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|GROUP PENSION ADMIN [1450]|GPA [145000]|33||||33|22.77|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33||||33|16.5|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|14.55|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33||||33|9.78|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|14.55|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33||||33|9.78|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|33||||33|9.78|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|PHCS [1780]|PHCS MULTIPLAN [178000]|33||||33|22.77|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33||||33|9.78|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|Self-pay|Self-pay|33||||33|11.55|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33||||33|9.78|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33||||33|9.78|22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33||||33||22.77|9.78
27212126|EAP|0272 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-STERI|HC STERILE WATER FOR INHALATION 1000ML|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33||||33||22.77|9.78
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|AARP [1000]|AARP [100000]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|AETNA [1015]|AETNA [101529]|324.45||||324.45|143.08|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|324.45||||324.45|96.2|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|BCBS [1155]|BCBS UTHCT [115568]|324.45||||324.45|152.49|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|324.45||||324.45|162.23|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|324.45||||324.45|162.23|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|324.45||||324.45|204.4|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|324.45||||324.45|96.2|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|CIGNA [1260]|CIGNA GWH [126023]|324.45||||324.45|178.45|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|324.45||||324.45|223.87|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|324.45||||324.45|152.49|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|324.45||||324.45|143.08|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|324.45||||324.45|96.2|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|324.45||||324.45|143.08|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|324.45||||324.45|96.2|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|324.45||||324.45|96.2|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|324.45||||324.45|223.87|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|324.45||||324.45|96.2|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|Self-pay|Self-pay|324.45||||324.45|113.56|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|324.45||||324.45|96.2|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|324.45||||324.45|96.2|223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|324.45||||324.45||223.87|96.2
27400015|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC IMMOB KNEE BARI UNIV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|324.45||||324.45||223.87|96.2
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|AARP [1000]|AARP [100000]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|AETNA [1015]|AETNA [101529]|56.7||||56.7|25|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56.7||||56.7|16.81|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|BCBS [1155]|BCBS UTHCT [115568]|56.7||||56.7|26.65|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56.7||||56.7|28.35|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56.7||||56.7|28.35|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56.7||||56.7|35.72|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56.7||||56.7|16.81|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|CIGNA [1260]|CIGNA GWH [126023]|56.7||||56.7|31.19|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|56.7||||56.7|39.12|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|56.7||||56.7|26.65|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56.7||||56.7|25|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56.7||||56.7|16.81|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56.7||||56.7|25|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|56.7||||56.7|16.81|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|56.7||||56.7|16.81|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|56.7||||56.7|39.12|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56.7||||56.7|16.81|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|Self-pay|Self-pay|56.7||||56.7|19.84|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|56.7||||56.7|16.81|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56.7||||56.7|16.81|39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56.7||||56.7||39.12|16.81
27400037|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 3 1/4 LG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|AARP [1000]|AARP [100000]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|AETNA [1015]|AETNA [101529]|56.7||||56.7|25|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56.7||||56.7|16.81|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|BCBS [1155]|BCBS UTHCT [115568]|56.7||||56.7|26.65|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56.7||||56.7|28.35|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56.7||||56.7|28.35|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56.7||||56.7|35.72|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56.7||||56.7|16.81|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|CIGNA [1260]|CIGNA GWH [126023]|56.7||||56.7|31.19|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|56.7||||56.7|39.12|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|56.7||||56.7|26.65|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56.7||||56.7|25|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56.7||||56.7|16.81|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56.7||||56.7|25|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|56.7||||56.7|16.81|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|56.7||||56.7|16.81|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|56.7||||56.7|39.12|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56.7||||56.7|16.81|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|Self-pay|Self-pay|56.7||||56.7|19.84|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|56.7||||56.7|16.81|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56.7||||56.7|16.81|39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56.7||||56.7||39.12|16.81
27400040|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC COLLAR IMMOB PHILLY 4 1/4 SM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|56.7||||56.7||39.12|16.81
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|AARP [1000]|AARP [100000]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|AETNA [1015]|AETNA [101529]|217.35||||217.35|95.85|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217.35||||217.35|64.44|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|BCBS [1155]|BCBS UTHCT [115568]|217.35||||217.35|102.15|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217.35||||217.35|108.68|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217.35||||217.35|108.68|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217.35||||217.35|136.93|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217.35||||217.35|64.44|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|CIGNA [1260]|CIGNA GWH [126023]|217.35||||217.35|119.54|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|217.35||||217.35|149.97|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|217.35||||217.35|102.15|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217.35||||217.35|95.85|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217.35||||217.35|64.44|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217.35||||217.35|95.85|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217.35||||217.35|64.44|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|217.35||||217.35|64.44|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|217.35||||217.35|149.97|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217.35||||217.35|64.44|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|Self-pay|Self-pay|217.35||||217.35|76.07|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|217.35||||217.35|64.44|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217.35||||217.35|64.44|149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217.35||||217.35||149.97|64.44
27410016|EAP|0274 - MEDICAL/SURGICAL SUPPLIES AND DEVICES-PROST|HC CERV FLEX N/ADJ FOAM PRE OTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217.35||||217.35||149.97|64.44
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|AARP [1000]|AARP [100000]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|AETNA [1015]|AETNA [101529]|447.95||||447.95|197.55|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|447.95||||447.95|132.82|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|BCBS [1155]|BCBS UTHCT [115568]|447.95||||447.95|210.54|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|447.95||||447.95|223.98|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|447.95||||447.95|223.98|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|447.95||||447.95|282.21|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|447.95||||447.95|132.82|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|CIGNA [1260]|CIGNA GWH [126023]|447.95||||447.95|246.37|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|447.95||||447.95|309.09|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|447.95||||447.95|223.98|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|447.95||||447.95|197.55|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|447.95||||447.95|132.82|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|447.95||||447.95|197.55|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|447.95||||447.95|132.82|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|447.95||||447.95|132.82|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|447.95||||447.95|309.09|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|447.95||||447.95|132.82|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|Self-pay|Self-pay|447.95||||447.95|156.78|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|447.95||||447.95|132.82|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|447.95||||447.95|132.82|309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|447.95||||447.95||309.09|132.82
27430|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INJECTION|300 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|447.95||||447.95||309.09|132.82
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|AARP [1000]|AARP [100000]|2402.5||||2402.5|1113.72|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2402.5||||2402.5|472.74|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|AETNA [1015]|AETNA [101529]|2402.5||||2402.5|1524.96|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2402.5||||2402.5|712.34|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2402.5||||2402.5|468.06|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2402.5||||2402.5|468.06|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|2402.5||||2402.5|1129.18|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2402.5||||2402.5|0|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2402.5||||2402.5|1201.25|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2402.5||||2402.5|1513.58|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2402.5||||2402.5|712.34|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2402.5||||2402.5|468.06|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|2402.5||||2402.5|1201.25|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2402.5||||2402.5|1657.73|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2402.5||||2402.5|373.5|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2402.5||||2402.5|468.06|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2402.5||||2402.5|1524.96|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2402.5||||2402.5|712.34|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2402.5||||2402.5|468.06|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2402.5||||2402.5|1524.96|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2402.5||||2402.5|712.34|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2402.5||||2402.5|712.34|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2402.5||||2402.5|1657.73|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2402.5||||2402.5|712.34|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|Self-pay|Self-pay|2402.5||||2402.5|840.87|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2402.5||||2402.5|712.34|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2402.5||||2402.5|712.34|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2402.5||||2402.5|1113.72|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2402.5||||2402.5|468.06|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2402.5||||2402.5|468.06|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2402.5||||2402.5|1113.72|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2402.5||||2402.5|468.06|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2402.5||||2402.5|936.11|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|AARP [1000]|AARP [100000]|6006.25||||6006.25|3003.13|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6006.25||||6006.25|1181.84|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|AETNA [1015]|AETNA [101529]|6006.25||||6006.25|3812.4|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6006.25||||6006.25|1780.85|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6006.25||||6006.25|1170.14|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6006.25||||6006.25|1170.14|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|BCBS [1155]|BCBS UTHCT [115568]|6006.25||||6006.25|2822.94|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6006.25||||6006.25|0|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6006.25||||6006.25|3003.13|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6006.25||||6006.25|3783.94|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6006.25||||6006.25|1780.85|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6006.25||||6006.25|1170.14|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|CIGNA [1260]|CIGNA GWH [126023]|6006.25||||6006.25|3003.13|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6006.25||||6006.25|4144.31|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6006.25||||6006.25|373.5|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6006.25||||6006.25|1170.14|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6006.25||||6006.25|3812.4|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6006.25||||6006.25|1780.85|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6006.25||||6006.25|1170.14|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6006.25||||6006.25|3812.4|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6006.25||||6006.25|1780.85|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6006.25||||6006.25|1780.85|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6006.25||||6006.25|4144.31|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6006.25||||6006.25|1780.85|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|Self-pay|Self-pay|6006.25||||6006.25|2102.19|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6006.25||||6006.25|1780.85|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6006.25||||6006.25|1780.85|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6006.25||||6006.25|3003.13|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6006.25||||6006.25|1170.14|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6006.25||||6006.25|1170.14|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6006.25||||6006.25|3003.13|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6006.25||||6006.25|1170.14|4144.31|373.5
27431|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION|25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6006.25||||6006.25|2340.28|4144.31|373.5
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|57.56||||57.56|25.38|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57.56||||57.56|17.07|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|57.56||||57.56|27.05|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|57.56||||57.56|28.78|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57.56||||57.56|28.78|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|57.56||||57.56|36.26|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|57.56||||57.56|17.07|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|57.56||||57.56|31.66|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|57.56||||57.56|39.72|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|57.56||||57.56|28.78|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57.56||||57.56|25.38|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57.56||||57.56|17.07|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57.56||||57.56|25.38|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57.56||||57.56|17.07|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|57.56||||57.56|17.07|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|57.56||||57.56|39.72|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57.56||||57.56|17.07|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|57.56||||57.56|20.15|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|57.56||||57.56|17.07|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|57.56||||57.56|17.07|39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57.56||||57.56||39.72|17.07
27462|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.025 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|57.56||||57.56|25.38|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57.56||||57.56|17.07|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|57.56||||57.56|27.05|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|57.56||||57.56|28.78|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57.56||||57.56|28.78|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|57.56||||57.56|36.26|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|57.56||||57.56|17.07|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|57.56||||57.56|31.66|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|57.56||||57.56|39.72|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|57.56||||57.56|28.78|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57.56||||57.56|25.38|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57.56||||57.56|17.07|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57.56||||57.56|25.38|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57.56||||57.56|17.07|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|57.56||||57.56|17.07|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|57.56||||57.56|39.72|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57.56||||57.56|17.07|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|57.56||||57.56|20.15|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|57.56||||57.56|17.07|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|57.56||||57.56|17.07|39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57.56||||57.56||39.72|17.07
27463|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.075 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|57.56||||57.56||39.72|17.07
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AARP [1000]|AARP [100000]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AETNA [1015]|AETNA [101529]|19.53||||19.53|8.61|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.53||||19.53|5.79|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BCBS UTHCT [115568]|19.53||||19.53|9.18|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.53||||19.53|9.77|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.53||||19.53|9.77|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.53||||19.53|12.3|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.53||||19.53|5.79|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|CIGNA [1260]|CIGNA GWH [126023]|19.53||||19.53|10.74|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.53||||19.53|13.48|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.53||||19.53|9.77|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.53||||19.53|8.61|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.53||||19.53|5.79|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.53||||19.53|8.61|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.53||||19.53|5.79|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.53||||19.53|5.79|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.53||||19.53|13.48|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.53||||19.53|5.79|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|Self-pay|Self-pay|19.53||||19.53|6.84|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.53||||19.53|5.79|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.53||||19.53|5.79|13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.53||||19.53||13.48|5.79
27466|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROSE 40 % ORAL GEL|94 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.53||||19.53||13.48|5.79
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AARP [1000]|AARP [100000]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AETNA [1015]|AETNA [101529]|2.53||||2.53|1.12|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.53||||2.53|0.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|2.53||||2.53|1.19|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.53||||2.53|1.27|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.53||||2.53|1.27|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.53||||2.53|1.59|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.53||||2.53|0.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|2.53||||2.53|1.39|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|2.53||||2.53|1.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.53||||2.53|1.27|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.53||||2.53|1.12|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.53||||2.53|0.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.53||||2.53|1.12|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.53||||2.53|0.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.53||||2.53|0.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|2.53||||2.53|1.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.53||||2.53|0.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|Self-pay|Self-pay|2.53||||2.53|0.89|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.53||||2.53|0.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.53||||2.53|0.75|1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.53||||2.53||1.75|0.75
27474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.53||||2.53||1.75|0.75
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AARP [1000]|AARP [100000]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AETNA [1015]|AETNA [101529]|3.22||||3.22|1.42|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.22||||3.22|0.95|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|3.22||||3.22|1.51|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.22||||3.22|1.61|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.22||||3.22|1.61|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.22||||3.22|2.03|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.22||||3.22|0.95|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|3.22||||3.22|1.77|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|3.22||||3.22|2.22|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.22||||3.22|1.61|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.22||||3.22|1.42|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.22||||3.22|0.95|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.22||||3.22|1.42|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.22||||3.22|0.95|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.22||||3.22|0.95|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|3.22||||3.22|2.22|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.22||||3.22|0.95|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|Self-pay|Self-pay|3.22||||3.22|1.13|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.22||||3.22|0.95|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.22||||3.22|0.95|2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.22||||3.22||2.22|0.95
27475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.6 MG/HR TRANSDERMAL 24 HOUR PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.22||||3.22||2.22|0.95
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|41.12||||41.12|18.13|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.12||||41.12|12.19|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|41.12||||41.12|19.33|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.12||||41.12|20.56|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.12||||41.12|20.56|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.12||||41.12|25.91|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.12||||41.12|12.19|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|41.12||||41.12|22.62|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|41.12||||41.12|28.37|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.12||||41.12|20.56|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.12||||41.12|18.13|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.12||||41.12|12.19|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.12||||41.12|18.13|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.12||||41.12|12.19|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.12||||41.12|12.19|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|41.12||||41.12|28.37|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.12||||41.12|12.19|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|41.12||||41.12|14.39|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.12||||41.12|12.19|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.12||||41.12|12.19|28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.12||||41.12||28.37|12.19
27505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.12||||41.12||28.37|12.19
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|138.31||||138.31|60.99|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138.31||||138.31|41.01|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|138.31||||138.31|65.01|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138.31||||138.31|69.16|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138.31||||138.31|69.16|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138.31||||138.31|87.14|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138.31||||138.31|41.01|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|138.31||||138.31|76.07|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|138.31||||138.31|95.43|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138.31||||138.31|69.16|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138.31||||138.31|60.99|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138.31||||138.31|41.01|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138.31||||138.31|60.99|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138.31||||138.31|41.01|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|138.31||||138.31|41.01|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|138.31||||138.31|95.43|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138.31||||138.31|41.01|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|138.31||||138.31|48.41|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138.31||||138.31|41.01|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138.31||||138.31|41.01|95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138.31||||138.31||95.43|41.01
27506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.2 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138.31||||138.31||95.43|41.01
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|191.86||||191.86|84.61|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|191.86||||191.86|56.89|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|191.86||||191.86|90.17|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|191.86||||191.86|95.93|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|191.86||||191.86|95.93|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|191.86||||191.86|120.87|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|191.86||||191.86|56.89|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|191.86||||191.86|105.52|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|191.86||||191.86|132.38|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|191.86||||191.86|95.93|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|191.86||||191.86|84.61|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|191.86||||191.86|56.89|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|191.86||||191.86|84.61|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|191.86||||191.86|56.89|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|191.86||||191.86|56.89|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|191.86||||191.86|132.38|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|191.86||||191.86|56.89|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|191.86||||191.86|67.15|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|191.86||||191.86|56.89|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|191.86||||191.86|56.89|132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|191.86||||191.86||132.38|56.89
27507|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONIDINE 0.3 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|191.86||||191.86||132.38|56.89
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AARP [1000]|AARP [100000]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AETNA [1015]|AETNA [101529]|2.6||||2.6|1.15|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.6||||2.6|0.77|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|2.6||||2.6|1.22|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.6||||2.6|1.3|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.6||||2.6|1.3|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.6||||2.6|1.64|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.6||||2.6|0.77|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|2.6||||2.6|1.43|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.6||||2.6|1.79|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.6||||2.6|1.3|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.6||||2.6|1.15|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.6||||2.6|0.77|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.6||||2.6|1.15|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.6||||2.6|0.77|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.6||||2.6|0.77|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.6||||2.6|1.79|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.6||||2.6|0.77|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|Self-pay|Self-pay|2.6||||2.6|0.91|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.6||||2.6|0.77|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.6||||2.6|0.77|1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.6||||2.6||1.79|0.77
27631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX 125 MG CAPSULE,DELAYED RELEASE SPRINKLE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.6||||2.6||1.79|0.77
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|AARP [1000]|AARP [100000]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|AETNA [1015]|AETNA [101529]|5.08||||5.08|2.24|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.08||||5.08|1.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|5.08||||5.08|2.39|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.08||||5.08|2.54|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.08||||5.08|2.54|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.08||||5.08|3.2|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.08||||5.08|1.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|5.08||||5.08|2.79|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.08||||5.08|3.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.08||||5.08|2.54|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.08||||5.08|2.24|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.08||||5.08|1.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.08||||5.08|2.24|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.08||||5.08|1.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.08||||5.08|1.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.08||||5.08|3.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.08||||5.08|1.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|Self-pay|Self-pay|5.08||||5.08|1.78|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.08||||5.08|1.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.08||||5.08|1.51|3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.08||||5.08||3.51|1.51
27633|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.08||||5.08||3.51|1.51
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AARP [1000]|AARP [100000]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AETNA [1015]|AETNA [101529]|5.16||||5.16|2.28|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.16||||5.16|1.53|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.16||||5.16|2.43|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.16||||5.16|2.58|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.16||||5.16|2.58|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.16||||5.16|3.25|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.16||||5.16|1.53|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.16||||5.16|2.84|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.16||||5.16|3.56|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.16||||5.16|2.58|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.16||||5.16|2.28|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.16||||5.16|1.53|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.16||||5.16|2.28|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.16||||5.16|1.53|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.16||||5.16|1.53|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.16||||5.16|3.56|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.16||||5.16|1.53|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|Self-pay|Self-pay|5.16||||5.16|1.81|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.16||||5.16|1.53|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.16||||5.16|1.53|3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.16||||5.16||3.56|1.53
27635|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.16||||5.16||3.56|1.53
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|9.68||||9.68|4.27|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.68||||9.68|2.87|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|9.68||||9.68|4.55|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.68||||9.68|4.84|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.68||||9.68|4.84|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.68||||9.68|6.1|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.68||||9.68|2.87|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|9.68||||9.68|5.32|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.68||||9.68|6.68|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.68||||9.68|4.84|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.68||||9.68|4.27|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.68||||9.68|2.87|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.68||||9.68|4.27|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.68||||9.68|2.87|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.68||||9.68|2.87|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.68||||9.68|6.68|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.68||||9.68|2.87|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|9.68||||9.68|3.39|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.68||||9.68|2.87|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.68||||9.68|2.87|6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.68||||9.68||6.68|2.87
27660|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 90 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.68||||9.68||6.68|2.87
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|AARP [1000]|AARP [100000]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|AETNA [1015]|AETNA [101529]|0.56||||0.56|0.25|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.56||||0.56|0.17|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|BCBS [1155]|BCBS UTHCT [115568]|0.56||||0.56|0.26|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.56||||0.56|0.28|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.56||||0.56|0.28|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.56||||0.56|0.35|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.56||||0.56|0.17|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|CIGNA [1260]|CIGNA GWH [126023]|0.56||||0.56|0.31|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|GROUP PENSION ADMIN [1450]|GPA [145000]|0.56||||0.56|0.39|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.56||||0.56|0.28|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.56||||0.56|0.25|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.56||||0.56|0.17|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.56||||0.56|0.25|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.56||||0.56|0.17|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.56||||0.56|0.17|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|PHCS [1780]|PHCS MULTIPLAN [178000]|0.56||||0.56|0.39|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.56||||0.56|0.17|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|Self-pay|Self-pay|0.56||||0.56|0.2|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.56||||0.56|0.17|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.56||||0.56|0.17|0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.56||||0.56||0.39|0.17
27663|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUORESCEIN 1 MG EYE STRIPS|1 strip|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.56||||0.56||0.39|0.17
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AARP [1000]|AARP [100000]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AETNA [1015]|AETNA [101529]|33.5||||33.5|14.77|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.5||||33.5|9.93|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BCBS UTHCT [115568]|33.5||||33.5|15.75|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.5||||33.5|16.75|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.5||||33.5|16.75|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.5||||33.5|21.11|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.5||||33.5|9.93|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|CIGNA [1260]|CIGNA GWH [126023]|33.5||||33.5|18.43|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|33.5||||33.5|23.12|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.5||||33.5|16.75|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.5||||33.5|14.77|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.5||||33.5|9.93|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.5||||33.5|14.77|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.5||||33.5|9.93|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.5||||33.5|9.93|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|33.5||||33.5|23.12|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.5||||33.5|9.93|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|Self-pay|Self-pay|33.5||||33.5|11.72|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.5||||33.5|9.93|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.5||||33.5|9.93|23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.5||||33.5||23.12|9.93
27666|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 20 % MUCOSAL SPRAY|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.5||||33.5||23.12|9.93
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AARP [1000]|AARP [100000]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|0.35||||0.35|0.15|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.35||||0.35|0.1|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.35||||0.35|0.16|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.35||||0.35|0.18|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.35||||0.35|0.18|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.35||||0.35|0.22|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.35||||0.35|0.1|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.35||||0.35|0.19|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.35||||0.35|0.24|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.35||||0.35|0.18|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.35||||0.35|0.15|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.35||||0.35|0.1|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.35||||0.35|0.15|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.35||||0.35|0.1|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.35||||0.35|0.1|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.35||||0.35|0.24|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.35||||0.35|0.1|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|Self-pay|Self-pay|0.35||||0.35|0.12|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.35||||0.35|0.1|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.35||||0.35|0.1|0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.35||||0.35||0.24|0.1
27694|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEPRAZOLE 20 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.35||||0.35||0.24|0.1
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.9||||1.9|0.19|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.9||||1.9|0.56|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.9||||1.9|0.89|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.9||||1.9|0|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.9||||1.9|0.95|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.9||||1.9|1.2|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.9||||1.9|0.56|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.9||||1.9|1.05|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.9||||1.9|1.31|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.9||||1.9|0.03|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.9||||1.9|0.19|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.9||||1.9|0.56|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.9||||1.9|0.19|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.9||||1.9|0.56|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.9||||1.9|0.56|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.9||||1.9|1.31|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.9||||1.9|0.56|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|1.9||||1.9|0.66|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.9||||1.9|0.56|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.9||||1.9|0.56|1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.9||||1.9||1.31|0.03
27697|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 4 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.9||||1.9||1.31|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.97||||1.97|0.38|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.97||||1.97|0.58|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.97||||1.97|0.93|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.97||||1.97|0|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.97||||1.97|0.99|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.97||||1.97|1.24|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.97||||1.97|0.58|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.97||||1.97|1.08|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.97||||1.97|1.36|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.97||||1.97|0.03|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.97||||1.97|0.38|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.97||||1.97|0.58|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.97||||1.97|0.38|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.97||||1.97|0.58|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.97||||1.97|0.58|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.97||||1.97|1.36|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.97||||1.97|0.58|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|1.97||||1.97|0.69|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.97||||1.97|0.58|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.97||||1.97|0.58|1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.97||||1.97||1.36|0.03
27698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ONDANSETRON 8 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.97||||1.97||1.36|0.03
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|AARP [1000]|AARP [100000]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|AETNA [1015]|AETNA [101529]|610.74||||610.74|269.34|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|610.74||||610.74|181.08|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|BCBS [1155]|BCBS UTHCT [115568]|610.74||||610.74|287.05|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|610.74||||610.74|305.37|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|610.74||||610.74|305.37|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|610.74||||610.74|384.77|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|610.74||||610.74|181.08|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|CIGNA [1260]|CIGNA GWH [126023]|610.74||||610.74|335.91|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|610.74||||610.74|421.41|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|610.74||||610.74|305.37|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|610.74||||610.74|269.34|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|610.74||||610.74|181.08|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|610.74||||610.74|269.34|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|610.74||||610.74|181.08|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|610.74||||610.74|181.08|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|610.74||||610.74|421.41|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|610.74||||610.74|181.08|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|Self-pay|Self-pay|610.74||||610.74|213.76|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|610.74||||610.74|181.08|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|610.74||||610.74|181.08|421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|610.74||||610.74||421.41|181.08
27770|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|610.74||||610.74||421.41|181.08
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.52||||1.52|0.67|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.52||||1.52|0.45|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.52||||1.52|0.71|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.52||||1.52|0.76|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.52||||1.52|0.76|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.52||||1.52|0.96|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.52||||1.52|0.45|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.52||||1.52|0.84|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.52||||1.52|1.05|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.52||||1.52|0.76|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.52||||1.52|0.67|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.52||||1.52|0.45|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.52||||1.52|0.67|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.52||||1.52|0.45|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.52||||1.52|0.45|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.52||||1.52|1.05|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.52||||1.52|0.45|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.52||||1.52|0.53|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.52||||1.52|0.45|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.52||||1.52|0.45|1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.52||||1.52||1.05|0.45
27780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZONISAMIDE 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.52||||1.52||1.05|0.45
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5|4.43|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|6.12|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|3.41|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|6.12|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|6.12|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5|4.43|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5|4.43|10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|3.41
27838|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SODIUM CHLORIDE 0.9 % INTRAVENOUS SOLUTION *BAG*|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|3.41
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|1.54||||1.54|0.68|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.54||||1.54|0.46|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.54||||1.54|0.72|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.54||||1.54|0.77|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.54||||1.54|0.77|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.54||||1.54|0.97|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.54||||1.54|0.46|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.54||||1.54|0.85|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.54||||1.54|1.06|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.54||||1.54|0.77|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.54||||1.54|0.68|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.54||||1.54|0.46|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.54||||1.54|0.68|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.54||||1.54|0.46|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.54||||1.54|0.46|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.54||||1.54|1.06|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.54||||1.54|0.46|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|1.54||||1.54|0.54|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.54||||1.54|0.46|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.54||||1.54|0.46|1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.54||||1.54||1.06|0.46
27857|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 37.5 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.54||||1.54||1.06|0.46
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|1.7||||1.7|0.75|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.7||||1.7|0.5|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.7||||1.7|0.8|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.7||||1.7|0.85|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.7||||1.7|0.85|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.7||||1.7|1.07|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.7||||1.7|0.5|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.7||||1.7|0.94|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.7||||1.7|1.17|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.7||||1.7|0.85|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.7||||1.7|0.75|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.7||||1.7|0.5|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.7||||1.7|0.75|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.7||||1.7|0.5|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.7||||1.7|0.5|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.7||||1.7|1.17|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.7||||1.7|0.5|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|1.7||||1.7|0.59|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.7||||1.7|0.5|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.7||||1.7|0.5|1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.7||||1.7||1.17|0.5
27858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 75 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.7||||1.7||1.17|0.5
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|1.93||||1.93|0.85|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.93||||1.93|0.57|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.93||||1.93|0.91|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.93||||1.93|0.97|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.93||||1.93|0.97|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.93||||1.93|1.22|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.93||||1.93|0.57|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.93||||1.93|1.06|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.93||||1.93|1.33|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.93||||1.93|0.97|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.93||||1.93|0.85|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.93||||1.93|0.57|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.93||||1.93|0.85|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.93||||1.93|0.57|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.93||||1.93|0.57|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.93||||1.93|1.33|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.93||||1.93|0.57|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|1.93||||1.93|0.68|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.93||||1.93|0.57|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.93||||1.93|0.57|1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.93||||1.93||1.33|0.57
27859|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VENLAFAXINE ER 150 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.93||||1.93||1.33|0.57
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|5.32||||5.32|2.35|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.32||||5.32|1.58|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|5.32||||5.32|2.5|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.32||||5.32|2.66|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.32||||5.32|2.66|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.32||||5.32|3.35|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.32||||5.32|1.58|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|5.32||||5.32|2.93|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|5.32||||5.32|3.67|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.32||||5.32|2.66|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.32||||5.32|2.35|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.32||||5.32|1.58|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.32||||5.32|2.35|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.32||||5.32|1.58|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.32||||5.32|1.58|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|5.32||||5.32|3.67|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.32||||5.32|1.58|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|5.32||||5.32|1.86|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.32||||5.32|1.58|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.32||||5.32|1.58|3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.32||||5.32||3.67|1.58
27860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.32||||5.32||3.67|1.58
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|5.75||||5.75|2.54|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.75||||5.75|1.7|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|5.75||||5.75|2.7|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.75||||5.75|2.88|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.75||||5.75|2.88|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.75||||5.75|3.62|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.75||||5.75|1.7|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|5.75||||5.75|3.16|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|5.75||||5.75|3.97|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.75||||5.75|2.88|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.75||||5.75|2.54|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.75||||5.75|1.7|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.75||||5.75|2.54|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.75||||5.75|1.7|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.75||||5.75|1.7|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|5.75||||5.75|3.97|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.75||||5.75|1.7|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|5.75||||5.75|2.01|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.75||||5.75|1.7|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.75||||5.75|1.7|3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.75||||5.75||3.97|1.7
27862|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 14 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.75||||5.75||3.97|1.7
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|5.32||||5.32|2.35|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.32||||5.32|1.58|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|5.32||||5.32|2.5|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.32||||5.32|2.66|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.32||||5.32|2.66|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.32||||5.32|3.35|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.32||||5.32|1.58|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|5.32||||5.32|2.93|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|5.32||||5.32|3.67|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.32||||5.32|2.66|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.32||||5.32|2.35|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.32||||5.32|1.58|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.32||||5.32|2.35|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.32||||5.32|1.58|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.32||||5.32|1.58|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|5.32||||5.32|3.67|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.32||||5.32|1.58|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|5.32||||5.32|1.86|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.32||||5.32|1.58|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.32||||5.32|1.58|3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.32||||5.32||3.67|1.58
27863|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NICOTINE 21 MG/24 HR DAILY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.32||||5.32||3.67|1.58
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|22.11||||22.11|9.75|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.11||||22.11|6.56|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|22.11||||22.11|10.39|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.11||||22.11|11.06|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.11||||22.11|11.06|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.11||||22.11|13.93|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.11||||22.11|6.56|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|22.11||||22.11|12.16|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|22.11||||22.11|15.26|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22.11||||22.11|11.06|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.11||||22.11|9.75|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.11||||22.11|6.56|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.11||||22.11|9.75|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.11||||22.11|6.56|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|22.11||||22.11|6.56|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|22.11||||22.11|15.26|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.11||||22.11|6.56|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|22.11||||22.11|7.74|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22.11||||22.11|6.56|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.11||||22.11|6.56|15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.11||||22.11||15.26|6.56
27905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 25 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.11||||22.11||15.26|6.56
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|39.27||||39.27|17.32|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.27||||39.27|11.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|39.27||||39.27|18.46|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.27||||39.27|19.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.27||||39.27|19.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.27||||39.27|24.74|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.27||||39.27|11.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|39.27||||39.27|21.6|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|39.27||||39.27|27.1|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|39.27||||39.27|19.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.27||||39.27|17.32|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.27||||39.27|11.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.27||||39.27|17.32|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.27||||39.27|11.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|39.27||||39.27|11.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|39.27||||39.27|27.1|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.27||||39.27|11.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|39.27||||39.27|13.74|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|39.27||||39.27|11.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.27||||39.27|11.64|27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.27||||39.27||27.1|11.64
27906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 50 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.27||||39.27||27.1|11.64
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|62.07||||62.07|27.37|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62.07||||62.07|18.4|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|62.07||||62.07|29.17|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|62.07||||62.07|31.04|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62.07||||62.07|31.04|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|62.07||||62.07|39.1|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|62.07||||62.07|18.4|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|62.07||||62.07|34.14|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|62.07||||62.07|42.83|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|62.07||||62.07|31.04|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62.07||||62.07|27.37|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62.07||||62.07|18.4|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62.07||||62.07|27.37|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|62.07||||62.07|18.4|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|62.07||||62.07|18.4|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|62.07||||62.07|42.83|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62.07||||62.07|18.4|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|62.07||||62.07|21.72|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|62.07||||62.07|18.4|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|62.07||||62.07|18.4|42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62.07||||62.07||42.83|18.4
27907|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 75 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|62.07||||62.07||42.83|18.4
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|85.43||||85.43|37.67|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|85.43||||85.43|25.33|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|85.43||||85.43|40.15|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|85.43||||85.43|42.72|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|85.43||||85.43|42.72|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|85.43||||85.43|53.82|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|85.43||||85.43|25.33|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|85.43||||85.43|46.99|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|85.43||||85.43|58.95|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|85.43||||85.43|42.72|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|85.43||||85.43|37.67|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|85.43||||85.43|25.33|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|85.43||||85.43|37.67|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|85.43||||85.43|25.33|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|85.43||||85.43|25.33|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|85.43||||85.43|58.95|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|85.43||||85.43|25.33|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|85.43||||85.43|29.9|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|85.43||||85.43|25.33|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|85.43||||85.43|25.33|58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|85.43||||85.43||58.95|25.33
27908|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 100 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|85.43||||85.43||58.95|25.33
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|111.6||||111.6|49.22|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111.6||||111.6|33.09|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|111.6||||111.6|52.45|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111.6||||111.6|55.8|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111.6||||111.6|55.8|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111.6||||111.6|70.31|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111.6||||111.6|33.09|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|111.6||||111.6|61.38|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|111.6||||111.6|77|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|111.6||||111.6|55.8|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111.6||||111.6|49.22|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111.6||||111.6|33.09|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111.6||||111.6|49.22|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111.6||||111.6|33.09|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|111.6||||111.6|33.09|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|111.6||||111.6|77|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111.6||||111.6|33.09|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|111.6||||111.6|39.06|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|111.6||||111.6|33.09|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111.6||||111.6|33.09|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111.6||||111.6||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|AARP [1000]|AARP [100000]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|AETNA [1015]|AETNA [101529]|217||||217|95.7|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217||||217|64.34|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BCBS UTHCT [115568]|217||||217|101.99|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217||||217|108.5|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217||||217|108.5|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217||||217|136.71|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217||||217|64.34|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|CIGNA [1260]|CIGNA GWH [126023]|217||||217|119.35|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|217||||217|149.73|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|217||||217|108.5|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217||||217|95.7|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217||||217|64.34|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217||||217|95.7|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217||||217|64.34|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|217||||217|64.34|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|217||||217|149.73|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217||||217|64.34|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|Self-pay|Self-pay|217||||217|75.95|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|217||||217|64.34|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217||||217|64.34|149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217||||217||149.73|33.09
27928|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 4.25 % IN 10 % DEXTROSE INTRAVENOUS SOLUTION|2,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217||||217||149.73|33.09
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|130.2||||130.2|57.42|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|130.2||||130.2|38.6|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|130.2||||130.2|61.19|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|130.2||||130.2|65.1|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|130.2||||130.2|65.1|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|130.2||||130.2|82.03|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|130.2||||130.2|38.6|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|130.2||||130.2|71.61|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|130.2||||130.2|89.84|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|130.2||||130.2|65.1|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|130.2||||130.2|57.42|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|130.2||||130.2|38.6|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|130.2||||130.2|57.42|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|130.2||||130.2|38.6|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|130.2||||130.2|38.6|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|130.2||||130.2|89.84|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|130.2||||130.2|38.6|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|130.2||||130.2|45.57|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|130.2||||130.2|38.6|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|130.2||||130.2|38.6|89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|130.2||||130.2||89.84|38.6
27933|ERX|0250 - PHARMACY-GENERAL|AMINO ACID 5 % IN 20 % DEXTROSE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|130.2||||130.2||89.84|38.6
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|124||||124|54.68|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|124||||124|36.77|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|124||||124|58.28|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|124||||124|62|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|124||||124|62|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|124||||124|78.12|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|124||||124|36.77|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|124||||124|68.2|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|124||||124|85.56|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|124||||124|62|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|124||||124|54.68|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|124||||124|36.77|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|124||||124|54.68|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|124||||124|36.77|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|124||||124|36.77|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|124||||124|85.56|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|124||||124|36.77|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|124||||124|43.4|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|124||||124|36.77|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|124||||124|36.77|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|124||||124||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|AARP [1000]|AARP [100000]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|AETNA [1015]|AETNA [101529]|229.4||||229.4|101.17|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|229.4||||229.4|68.02|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BCBS UTHCT [115568]|229.4||||229.4|107.82|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|229.4||||229.4|114.7|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|229.4||||229.4|114.7|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|229.4||||229.4|144.52|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|229.4||||229.4|68.02|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|CIGNA [1260]|CIGNA GWH [126023]|229.4||||229.4|126.17|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|229.4||||229.4|158.29|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|229.4||||229.4|114.7|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|229.4||||229.4|101.17|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|229.4||||229.4|68.02|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|229.4||||229.4|101.17|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|229.4||||229.4|68.02|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|229.4||||229.4|68.02|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|229.4||||229.4|158.29|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|229.4||||229.4|68.02|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|Self-pay|Self-pay|229.4||||229.4|80.29|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|229.4||||229.4|68.02|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|229.4||||229.4|68.02|158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|229.4||||229.4||158.29|36.77
27947|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 4.25 % WITH LYTES AND CALCIUM IN D5W INTRAVENOUS SOLUTION|2,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|229.4||||229.4||158.29|36.77
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|130.2||||130.2|57.42|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|130.2||||130.2|38.6|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|130.2||||130.2|61.19|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|130.2||||130.2|65.1|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|130.2||||130.2|65.1|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|130.2||||130.2|82.03|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|130.2||||130.2|38.6|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|130.2||||130.2|71.61|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|130.2||||130.2|89.84|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|130.2||||130.2|65.1|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|130.2||||130.2|57.42|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|130.2||||130.2|38.6|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|130.2||||130.2|57.42|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|130.2||||130.2|38.6|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|130.2||||130.2|38.6|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|130.2||||130.2|89.84|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|130.2||||130.2|38.6|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|130.2||||130.2|45.57|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|130.2||||130.2|38.6|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|130.2||||130.2|38.6|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|130.2||||130.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|AARP [1000]|AARP [100000]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|AETNA [1015]|AETNA [101529]|254.2||||254.2|112.1|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|254.2||||254.2|75.37|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BCBS UTHCT [115568]|254.2||||254.2|119.47|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|254.2||||254.2|127.1|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|254.2||||254.2|127.1|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|254.2||||254.2|160.15|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|254.2||||254.2|75.37|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|CIGNA [1260]|CIGNA GWH [126023]|254.2||||254.2|139.81|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|254.2||||254.2|175.4|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|254.2||||254.2|127.1|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|254.2||||254.2|112.1|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|254.2||||254.2|75.37|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|254.2||||254.2|112.1|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|254.2||||254.2|75.37|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|254.2||||254.2|75.37|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|254.2||||254.2|175.4|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|254.2||||254.2|75.37|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|Self-pay|Self-pay|254.2||||254.2|88.97|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|254.2||||254.2|75.37|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|254.2||||254.2|75.37|175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|254.2||||254.2||175.4|38.6
27964|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 5 % WITH LYTES AND CALCIUM IN D20W INTRAVENOUS SOLUTION|2,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|254.2||||254.2||175.4|38.6
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|18.37||||18.37|8.1|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.37||||18.37|5.45|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|18.37||||18.37|8.63|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.37||||18.37|9.19|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.37||||18.37|9.19|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.37||||18.37|11.57|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.37||||18.37|5.45|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|18.37||||18.37|10.1|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.37||||18.37|12.68|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.37||||18.37|9.19|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.37||||18.37|8.1|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.37||||18.37|5.45|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.37||||18.37|8.1|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.37||||18.37|5.45|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.37||||18.37|5.45|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.37||||18.37|12.68|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.37||||18.37|5.45|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|Self-pay|Self-pay|18.37||||18.37|6.43|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.37||||18.37|5.45|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.37||||18.37|5.45|12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.37||||18.37||12.68|5.45
27994|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL 1.4 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.37||||18.37||12.68|5.45
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AARP [1000]|AARP [100000]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AETNA [1015]|AETNA [101529]|4.39||||4.39|1.94|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.39||||4.39|1.3|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS [1155]|BCBS UTHCT [115568]|4.39||||4.39|2.06|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.39||||4.39|2.2|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.39||||4.39|2.2|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.39||||4.39|2.77|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.39||||4.39|1.3|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|CIGNA [1260]|CIGNA GWH [126023]|4.39||||4.39|2.41|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.39||||4.39|3.03|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.39||||4.39|2.2|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.39||||4.39|1.94|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.39||||4.39|1.3|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.39||||4.39|1.94|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.39||||4.39|1.3|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.39||||4.39|1.3|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.39||||4.39|3.03|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.39||||4.39|1.3|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|Self-pay|Self-pay|4.39||||4.39|1.54|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.39||||4.39|1.3|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.39||||4.39|1.3|3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.39||||4.39||3.03|1.3
28055|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALAMINE 8 %-ZINC OXIDE 8 % LOTION|177 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.39||||4.39||3.03|1.3
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|6.84|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|7.75|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|7.75|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|6.84|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|6.84|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|4.6
28115|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|6.84|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|7.75|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|7.75|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|6.84|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|6.84|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|4.6
28116|ERX|0258 - PHARMACY-IV SOLUTIONS|ELECTROLYTE-R (PH 7.4) INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|4.6
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.95||||2.95|1.3|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.95||||2.95|0.87|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.95||||2.95|1.39|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.95||||2.95|1.48|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.95||||2.95|1.48|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.95||||2.95|1.86|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.95||||2.95|0.87|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.95||||2.95|1.62|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.95||||2.95|2.04|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.95||||2.95|1.48|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.95||||2.95|1.3|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.95||||2.95|0.87|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.95||||2.95|1.3|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.95||||2.95|0.87|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.95||||2.95|0.87|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.95||||2.95|2.04|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.95||||2.95|0.87|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|Self-pay|Self-pay|2.95||||2.95|1.03|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.95||||2.95|0.87|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.95||||2.95|0.87|2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.95||||2.95||2.04|0.87
28158|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.95||||2.95||2.04|0.87
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.36||||5.36|2.36|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.36||||5.36|1.59|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.36||||5.36|2.52|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.36||||5.36|2.68|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.36||||5.36|2.68|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.36||||5.36|3.38|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.36||||5.36|1.59|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.36||||5.36|2.95|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.36||||5.36|3.7|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.36||||5.36|2.68|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.36||||5.36|2.36|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.36||||5.36|1.59|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.36||||5.36|2.36|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.36||||5.36|1.59|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.36||||5.36|1.59|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.36||||5.36|3.7|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.36||||5.36|1.59|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|5.36||||5.36|1.88|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.36||||5.36|1.59|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.36||||5.36|1.59|3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.36||||5.36||3.7|1.59
28159|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 5 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.36||||5.36||3.7|1.59
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.9||||3.9|1.72|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.9||||3.9|1.16|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.9||||3.9|1.83|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.9||||3.9|1.95|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.9||||3.9|1.95|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.9||||3.9|2.46|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.9||||3.9|1.16|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.9||||3.9|2.15|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.9||||3.9|2.69|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.9||||3.9|1.95|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.9||||3.9|1.72|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.9||||3.9|1.16|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.9||||3.9|1.72|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.9||||3.9|1.16|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.9||||3.9|1.16|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.9||||3.9|2.69|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.9||||3.9|1.16|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|3.9||||3.9|1.36|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.9||||3.9|1.16|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.9||||3.9|1.16|2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.9||||3.9||2.69|1.16
28160|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OLANZAPINE 10 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.9||||3.9||2.69|1.16
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AARP [1000]|AARP [100000]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|9.29||||9.29|4.1|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.29||||9.29|2.75|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|9.29||||9.29|4.37|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.29||||9.29|4.65|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.29||||9.29|4.65|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.29||||9.29|5.85|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.29||||9.29|2.75|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|9.29||||9.29|5.11|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|9.29||||9.29|6.41|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.29||||9.29|4.65|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.29||||9.29|4.1|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.29||||9.29|2.75|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.29||||9.29|4.1|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.29||||9.29|2.75|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.29||||9.29|2.75|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|9.29||||9.29|6.41|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.29||||9.29|2.75|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|Self-pay|Self-pay|9.29||||9.29|3.25|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.29||||9.29|2.75|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.29||||9.29|2.75|6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.29||||9.29||6.41|2.75
28203|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.29||||9.29||6.41|2.75
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.12||||19.12|8.43|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.12||||19.12|5.67|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|19.12||||19.12|8.99|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.12||||19.12|9.56|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.12||||19.12|9.56|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.12||||19.12|12.05|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.12||||19.12|5.67|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|19.12||||19.12|10.52|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.12||||19.12|13.19|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.12||||19.12|9.56|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.12||||19.12|8.43|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.12||||19.12|5.67|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.12||||19.12|8.43|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.12||||19.12|5.67|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.12||||19.12|5.67|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.12||||19.12|13.19|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.12||||19.12|5.67|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|Self-pay|Self-pay|19.12||||19.12|6.69|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.12||||19.12|5.67|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.12||||19.12|5.67|13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.12||||19.12||13.19|5.67
28224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 600 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.12||||19.12||13.19|5.67
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|AARP [1000]|AARP [100000]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|AETNA [1015]|AETNA [101529]|418.6||||418.6|184.6|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|418.6||||418.6|124.11|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|418.6||||418.6|196.74|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|418.6||||418.6|209.3|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|418.6||||418.6|209.3|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|418.6||||418.6|263.72|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|418.6||||418.6|124.11|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|418.6||||418.6|230.23|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|418.6||||418.6|288.83|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|418.6||||418.6|209.3|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|418.6||||418.6|184.6|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|418.6||||418.6|124.11|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|418.6||||418.6|184.6|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|418.6||||418.6|124.11|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|418.6||||418.6|124.11|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|418.6||||418.6|288.83|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|418.6||||418.6|124.11|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|Self-pay|Self-pay|418.6||||418.6|146.51|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|418.6||||418.6|124.11|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|418.6||||418.6|124.11|288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|418.6||||418.6||288.83|124.11
28225|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINEZOLID 100 MG/5 ML ORAL SUSPENSION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|418.6||||418.6||288.83|124.11
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AARP [1000]|AARP [100000]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AETNA [1015]|AETNA [101529]|123.69||||123.69|46.51|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|123.69||||123.69|36.67|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS [1155]|BCBS UTHCT [115568]|123.69||||123.69|58.13|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|123.69||||123.69|0|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|123.69||||123.69|61.85|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|123.69||||123.69|77.92|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|123.69||||123.69|36.67|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|CIGNA [1260]|CIGNA GWH [126023]|123.69||||123.69|68.03|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|123.69||||123.69|85.35|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|123.69||||123.69|8.84|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|123.69||||123.69|46.51|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|123.69||||123.69|36.67|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|123.69||||123.69|46.51|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|123.69||||123.69|36.67|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|123.69||||123.69|36.67|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|123.69||||123.69|85.35|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|123.69||||123.69|36.67|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|Self-pay|Self-pay|123.69||||123.69|43.29|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|123.69||||123.69|36.67|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|123.69||||123.69|36.67|85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|123.69||||123.69||85.35|8.84
28226|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LINEZOLID IN 5% DEXTROSE IN WATER 600 MG/300 ML INTRAVENOUS PIGGYBACK|300 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|123.69||||123.69||85.35|8.84
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AARP [1000]|AARP [100000]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AETNA [1015]|AETNA [101529]|517.36||||517.36|228.16|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|517.36||||517.36|153.4|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS [1155]|BCBS UTHCT [115568]|517.36||||517.36|243.16|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|517.36||||517.36|258.68|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|517.36||||517.36|258.68|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|517.36||||517.36|325.94|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|517.36||||517.36|153.4|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|CIGNA [1260]|CIGNA GWH [126023]|517.36||||517.36|284.55|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|517.36||||517.36|356.98|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|517.36||||517.36|258.68|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|517.36||||517.36|228.16|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|517.36||||517.36|153.4|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|517.36||||517.36|228.16|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|517.36||||517.36|153.4|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|517.36||||517.36|153.4|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|517.36||||517.36|356.98|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|517.36||||517.36|153.4|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|Self-pay|Self-pay|517.36||||517.36|181.08|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|517.36||||517.36|153.4|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|517.36||||517.36|153.4|356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|517.36||||517.36||356.98|153.4
28235|ERX|0250 - PHARMACY-GENERAL|PENTAMIDINE 300 MG SOLUTION FOR INHALATION|300 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|517.36||||517.36||356.98|153.4
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.24||||1.24|0.55|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.24||||1.24|0.37|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.24||||1.24|0.58|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.24||||1.24|0.62|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.24||||1.24|0.62|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.24||||1.24|0.78|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.24||||1.24|0.37|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.24||||1.24|0.68|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.24||||1.24|0.86|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.24||||1.24|0.62|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.24||||1.24|0.55|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.24||||1.24|0.37|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.24||||1.24|0.55|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.24||||1.24|0.37|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.24||||1.24|0.37|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.24||||1.24|0.86|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.24||||1.24|0.37|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|Self-pay|Self-pay|1.24||||1.24|0.43|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.24||||1.24|0.37|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.24||||1.24|0.37|0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.24||||1.24||0.86|0.37
28252|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 160 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.24||||1.24||0.86|0.37
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.24||||3.24|1.43|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.24||||3.24|0.96|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|3.24||||3.24|1.52|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.24||||3.24|1.62|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.24||||3.24|1.62|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.24||||3.24|2.04|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.24||||3.24|0.96|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|3.24||||3.24|1.78|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.24||||3.24|2.24|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.24||||3.24|1.62|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.24||||3.24|1.43|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.24||||3.24|0.96|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.24||||3.24|1.43|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.24||||3.24|0.96|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.24||||3.24|0.96|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.24||||3.24|2.24|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.24||||3.24|0.96|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|3.24||||3.24|1.13|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.24||||3.24|0.96|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.24||||3.24|0.96|2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.24||||3.24||2.24|0.96
28278|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RIVASTIGMINE 1.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.24||||3.24||2.24|0.96
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|879.04||||879.04|398.4|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|879.04||||879.04|260.64|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|879.04||||879.04|413.15|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|879.04||||879.04|0|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|879.04||||879.04|439.52|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|879.04||||879.04|553.8|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|879.04||||879.04|260.64|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|879.04||||879.04|439.52|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|879.04||||879.04|606.54|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|879.04||||879.04|439.52|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|879.04||||879.04|398.4|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|879.04||||879.04|260.64|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|879.04||||879.04|398.4|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|879.04||||879.04|260.64|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|879.04||||879.04|260.64|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|879.04||||879.04|606.54|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|879.04||||879.04|260.64|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|Self-pay|Self-pay|879.04||||879.04|307.66|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|879.04||||879.04|260.64|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|879.04||||879.04|260.64|606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|879.04||||879.04||606.54|260.64
28282|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE (U-100) 100 UNIT/ML SUBCUTANEOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|879.04||||879.04||606.54|260.64
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.63||||0.63|0.28|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.63||||0.63|0.19|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.63||||0.63|0.3|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.63||||0.63|0.32|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.63||||0.63|0.32|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.63||||0.63|0.4|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.63||||0.63|0.19|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.63||||0.63|0.35|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.63||||0.63|0.43|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.63||||0.63|0.32|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.63||||0.63|0.28|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.63||||0.63|0.19|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.63||||0.63|0.28|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.63||||0.63|0.19|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.63||||0.63|0.19|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.63||||0.63|0.43|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.63||||0.63|0.19|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|Self-pay|Self-pay|0.63||||0.63|0.22|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.63||||0.63|0.19|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.63||||0.63|0.19|0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.63||||0.63||0.43|0.19
28384|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 10 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.63||||0.63||0.43|0.19
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|6.84|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|7.75|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|7.75|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|6.84|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|6.84|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|4.6
28400|ERX|0250 - PHARMACY-GENERAL|WATER FOR INJECTION, STERILE INTRAVENOUS SOLUTION *BAG*|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|4.6
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|57.56||||57.56|25.38|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57.56||||57.56|17.07|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|57.56||||57.56|27.05|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|57.56||||57.56|28.78|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57.56||||57.56|28.78|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|57.56||||57.56|36.26|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|57.56||||57.56|17.07|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|57.56||||57.56|31.66|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|57.56||||57.56|39.72|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|57.56||||57.56|28.78|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57.56||||57.56|25.38|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57.56||||57.56|17.07|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57.56||||57.56|25.38|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57.56||||57.56|17.07|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|57.56||||57.56|17.07|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|57.56||||57.56|39.72|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57.56||||57.56|17.07|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|57.56||||57.56|20.15|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|57.56||||57.56|17.07|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|57.56||||57.56|17.07|39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57.56||||57.56||39.72|17.07
28409|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.1 MG/24 HR WEEKLY TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|57.56||||57.56||39.72|17.07
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|4.62||||4.62|2.04|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.62||||4.62|1.37|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.62||||4.62|2.17|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.62||||4.62|2.31|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.62||||4.62|2.31|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.62||||4.62|2.91|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.62||||4.62|1.37|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.62||||4.62|2.54|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.62||||4.62|3.19|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.62||||4.62|2.31|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.62||||4.62|2.04|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.62||||4.62|1.37|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.62||||4.62|2.04|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.62||||4.62|1.37|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.62||||4.62|1.37|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.62||||4.62|3.19|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.62||||4.62|1.37|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|4.62||||4.62|1.62|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.62||||4.62|1.37|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.62||||4.62|1.37|3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.62||||4.62||3.19|1.37
28643|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIFEDIPINE ER 30 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.62||||4.62||3.19|1.37
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AARP [1000]|AARP [100000]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA [1015]|AETNA [101529]|24.51||||24.51|10.81|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.51||||24.51|7.27|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|24.51||||24.51|11.52|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.51||||24.51|12.26|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.51||||24.51|12.26|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.51||||24.51|15.44|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.51||||24.51|7.27|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|24.51||||24.51|13.48|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.51||||24.51|16.91|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.51||||24.51|12.26|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.51||||24.51|10.81|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.51||||24.51|7.27|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.51||||24.51|10.81|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.51||||24.51|7.27|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.51||||24.51|7.27|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.51||||24.51|16.91|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.51||||24.51|7.27|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|Self-pay|Self-pay|24.51||||24.51|8.58|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.51||||24.51|7.27|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.51||||24.51|7.27|16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.51||||24.51||16.91|7.27
28774|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.51||||24.51||16.91|7.27
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AARP [1000]|AARP [100000]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AETNA [1015]|AETNA [101529]|28.85||||28.85|12.72|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.85||||28.85|8.55|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|28.85||||28.85|13.56|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.85||||28.85|14.43|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.85||||28.85|14.43|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.85||||28.85|18.18|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.85||||28.85|8.55|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|28.85||||28.85|15.87|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|28.85||||28.85|19.91|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|28.85||||28.85|14.43|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.85||||28.85|12.72|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.85||||28.85|8.55|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.85||||28.85|12.72|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.85||||28.85|8.55|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|28.85||||28.85|8.55|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|28.85||||28.85|19.91|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.85||||28.85|8.55|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|Self-pay|Self-pay|28.85||||28.85|10.1|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|28.85||||28.85|8.55|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.85||||28.85|8.55|19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.85||||28.85||19.91|8.55
28775|ERX|0250 - PHARMACY-GENERAL|BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.85||||28.85||19.91|8.55
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AARP [1000]|AARP [100000]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AETNA [1015]|AETNA [101529]|214.83||||214.83|94.74|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214.83||||214.83|63.7|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS [1155]|BCBS UTHCT [115568]|214.83||||214.83|100.97|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214.83||||214.83|107.42|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214.83||||214.83|107.42|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214.83||||214.83|135.34|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214.83||||214.83|63.7|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|CIGNA [1260]|CIGNA GWH [126023]|214.83||||214.83|118.16|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|214.83||||214.83|148.23|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214.83||||214.83|107.42|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214.83||||214.83|94.74|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214.83||||214.83|63.7|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214.83||||214.83|94.74|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214.83||||214.83|63.7|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|214.83||||214.83|63.7|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|214.83||||214.83|148.23|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214.83||||214.83|63.7|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|Self-pay|Self-pay|214.83||||214.83|75.19|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214.83||||214.83|63.7|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214.83||||214.83|63.7|148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214.83||||214.83||148.23|63.7
28824|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 2.5 % TOPICAL CREAM WITH PERINEAL APPLICATOR|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214.83||||214.83||148.23|63.7
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AARP [1000]|AARP [100000]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AETNA [1015]|AETNA [101529]|92.82||||92.82|40.93|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92.82||||92.82|27.52|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS [1155]|BCBS UTHCT [115568]|92.82||||92.82|43.63|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92.82||||92.82|46.41|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92.82||||92.82|46.41|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92.82||||92.82|58.48|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92.82||||92.82|27.52|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|CIGNA [1260]|CIGNA GWH [126023]|92.82||||92.82|51.05|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|GROUP PENSION ADMIN [1450]|GPA [145000]|92.82||||92.82|64.05|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|92.82||||92.82|46.41|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92.82||||92.82|40.93|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92.82||||92.82|27.52|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92.82||||92.82|40.93|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92.82||||92.82|27.52|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|92.82||||92.82|27.52|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|PHCS [1780]|PHCS MULTIPLAN [178000]|92.82||||92.82|64.05|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92.82||||92.82|27.52|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|Self-pay|Self-pay|92.82||||92.82|32.49|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|92.82||||92.82|27.52|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92.82||||92.82|27.52|64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92.82||||92.82||64.05|27.52
2888|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ERYTHROMYCIN 5 MG/GRAM (0.5 %) EYE OINTMENT|4 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92.82||||92.82||64.05|27.52
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.96||||2.96|1.31|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.96||||2.96|0.88|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.96||||2.96|1.39|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.96||||2.96|1.48|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.96||||2.96|1.48|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.96||||2.96|1.86|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.96||||2.96|0.88|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.96||||2.96|1.63|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.96||||2.96|2.04|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.96||||2.96|1.48|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.96||||2.96|1.31|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.96||||2.96|0.88|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.96||||2.96|1.31|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.96||||2.96|0.88|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.96||||2.96|0.88|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.96||||2.96|2.04|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.96||||2.96|0.88|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|Self-pay|Self-pay|2.96||||2.96|1.04|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.96||||2.96|0.88|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.96||||2.96|0.88|2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.96||||2.96||2.04|0.88
28899|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.96||||2.96||2.04|0.88
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AARP [1000]|AARP [100000]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AETNA [1015]|AETNA [101529]|1550||||1550|1550|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1550||||1550|459.58|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|1550||||1550|728.5|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1550||||1550|0|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1550||||1550|775|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1550||||1550|976.5|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1550||||1550|459.58|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|1550||||1550|775|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1550||||1550|1069.5|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1550||||1550|1.81|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1550||||1550|1550|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1550||||1550|459.58|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1550||||1550|1550|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1550||||1550|459.58|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1550||||1550|459.58|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1550||||1550|1069.5|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1550||||1550|459.58|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|Self-pay|Self-pay|1550||||1550|542.5|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1550||||1550|459.58|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1550||||1550|459.58|1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1550||||1550||1550|1.81
28947|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ARGATROBAN 100 MG/ML INTRAVENOUS SOLUTION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1550||||1550||1550|1.81
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|41.75||||41.75|16.1|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.75||||41.75|12.38|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|41.75||||41.75|19.62|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.75||||41.75|0|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.75||||41.75|20.88|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.75||||41.75|26.3|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.75||||41.75|12.38|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|41.75||||41.75|22.96|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|41.75||||41.75|28.81|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.75||||41.75|8.13|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.75||||41.75|16.1|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.75||||41.75|12.38|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.75||||41.75|16.1|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.75||||41.75|12.38|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.75||||41.75|12.38|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|41.75||||41.75|28.81|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.75||||41.75|12.38|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|Self-pay|Self-pay|41.75||||41.75|14.61|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.75||||41.75|12.38|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.75||||41.75|12.38|28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.75||||41.75||28.81|8.13
28958|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SIROLIMUS 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.75||||41.75||28.81|8.13
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.48||||2.48|1.09|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.48||||2.48|0.74|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.48||||2.48|1.17|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.48||||2.48|1.24|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.48||||2.48|1.24|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.48||||2.48|1.56|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.48||||2.48|0.74|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.48||||2.48|1.36|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.48||||2.48|1.71|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.48||||2.48|1.24|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.48||||2.48|1.09|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.48||||2.48|0.74|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.48||||2.48|1.09|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.48||||2.48|0.74|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.48||||2.48|0.74|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.48||||2.48|1.71|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.48||||2.48|0.74|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|Self-pay|Self-pay|2.48||||2.48|0.87|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.48||||2.48|0.74|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.48||||2.48|0.74|1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.48||||2.48||1.71|0.74
28964|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 750 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.48||||2.48||1.71|0.74
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|253.6||||253.6|189.79|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|253.6||||253.6|75.19|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|253.6||||253.6|119.19|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|253.6||||253.6|0|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|253.6||||253.6|126.8|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|253.6||||253.6|159.77|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|253.6||||253.6|75.19|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|253.6||||253.6|139.48|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|253.6||||253.6|174.98|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|253.6||||253.6|96.06|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|253.6||||253.6|189.79|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|253.6||||253.6|75.19|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|253.6||||253.6|189.79|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|253.6||||253.6|75.19|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|253.6||||253.6|75.19|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|253.6||||253.6|174.98|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|253.6||||253.6|75.19|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|253.6||||253.6|88.76|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|253.6||||253.6|75.19|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|253.6||||253.6|75.19|189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|253.6||||253.6||189.79|75.19
2903|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERYTHROMYCIN LACTOBIONATE 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|253.6||||253.6||189.79|75.19
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.27||||4.27|1.88|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.27||||4.27|1.27|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.27||||4.27|2.01|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.27||||4.27|2.14|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.27||||4.27|2.14|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.27||||4.27|2.69|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.27||||4.27|1.27|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.27||||4.27|2.35|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.27||||4.27|2.95|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.27||||4.27|2.14|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.27||||4.27|1.88|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.27||||4.27|1.27|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.27||||4.27|1.88|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.27||||4.27|1.27|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.27||||4.27|1.27|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.27||||4.27|2.95|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.27||||4.27|1.27|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|Self-pay|Self-pay|4.27||||4.27|1.49|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.27||||4.27|1.27|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.27||||4.27|1.27|2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.27||||4.27||2.95|1.27
29048|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALENDRONATE 70 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.27||||4.27||2.95|1.27
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|170.5||||170.5|47|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170.5||||170.5||117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|170.5||||170.5|50.4|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170.5||||170.5|50.55|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170.5||||170.5||117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|170.5||||170.5||117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|170.5||||170.5|80.14|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170.5||||170.5|0|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170.5||||170.5|85.25|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170.5||||170.5|107.42|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170.5||||170.5|50.55|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170.5||||170.5||117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|170.5||||170.5|93.78|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|170.5||||170.5|117.65|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|170.5||||170.5|0.28|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|170.5||||170.5||117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170.5||||170.5|50.4|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170.5||||170.5|50.55|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170.5||||170.5||117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170.5||||170.5|50.4|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|170.5||||170.5|50.55|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|170.5||||170.5|50.55|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|170.5||||170.5|117.65|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170.5||||170.5|50.55|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|170.5||||170.5|59.67|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|170.5||||170.5|50.55|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170.5||||170.5|50.55|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170.5||||170.5|47|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|170.5||||170.5||117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|170.5||||170.5||117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170.5||||170.5|47|117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170.5||||170.5||117.65|0.28
29132|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRON SUCROSE 100 MG IRON/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|170.5||||170.5||117.65|0.28
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AARP [1000]|AARP [100000]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AETNA [1015]|AETNA [101529]|345.31||||345.31|152.28|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|345.31||||345.31|102.38|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS [1155]|BCBS UTHCT [115568]|345.31||||345.31|162.3|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|345.31||||345.31|172.66|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|345.31||||345.31|172.66|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|345.31||||345.31|217.55|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|345.31||||345.31|102.38|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|CIGNA [1260]|CIGNA GWH [126023]|345.31||||345.31|189.92|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|345.31||||345.31|238.26|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|345.31||||345.31|172.66|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|345.31||||345.31|152.28|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|345.31||||345.31|102.38|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|345.31||||345.31|152.28|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|345.31||||345.31|102.38|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|345.31||||345.31|102.38|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|345.31||||345.31|238.26|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|345.31||||345.31|102.38|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|Self-pay|Self-pay|345.31||||345.31|120.86|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|345.31||||345.31|102.38|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|345.31||||345.31|102.38|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|470 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|345.31||||345.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|2.31||||2.31|1.02|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.31||||2.31|0.68|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|2.31||||2.31|1.09|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.31||||2.31|1.16|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.31||||2.31|1.16|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.31||||2.31|1.46|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.31||||2.31|0.68|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|2.31||||2.31|1.27|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.31||||2.31|1.59|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.31||||2.31|1.16|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.31||||2.31|1.02|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.31||||2.31|0.68|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.31||||2.31|1.02|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.31||||2.31|0.68|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.31||||2.31|0.68|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.31||||2.31|1.59|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.31||||2.31|0.68|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|Self-pay|Self-pay|2.31||||2.31|0.81|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.31||||2.31|0.68|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.31||||2.31|0.68|238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.31||||2.31||238.26|0.68
29169|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GABAPENTIN 250 MG/5 ML ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.31||||2.31||238.26|0.68
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.09||||2.09|0.92|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.09||||2.09|0.62|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.09||||2.09|0.98|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.09||||2.09|1.05|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.09||||2.09|1.05|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.09||||2.09|1.32|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.09||||2.09|0.62|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.09||||2.09|1.15|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.09||||2.09|1.44|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.09||||2.09|1.05|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.09||||2.09|0.92|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.09||||2.09|0.62|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.09||||2.09|0.92|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.09||||2.09|0.62|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.09||||2.09|0.62|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.09||||2.09|1.44|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.09||||2.09|0.62|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|Self-pay|Self-pay|2.09||||2.09|0.73|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.09||||2.09|0.62|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.09||||2.09|0.62|1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.09||||2.09||1.44|0.62
29267|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.09||||2.09||1.44|0.62
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|1.9||||1.9|0.84|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.9||||1.9|0.56|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.9||||1.9|0.89|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.9||||1.9|0.95|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.9||||1.9|0.95|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.9||||1.9|1.2|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.9||||1.9|0.56|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.9||||1.9|1.05|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.9||||1.9|1.31|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.9||||1.9|0.95|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.9||||1.9|0.84|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.9||||1.9|0.56|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.9||||1.9|0.84|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.9||||1.9|0.56|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.9||||1.9|0.56|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.9||||1.9|1.31|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.9||||1.9|0.56|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|1.9||||1.9|0.66|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.9||||1.9|0.56|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.9||||1.9|0.56|1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.9||||1.9||1.31|0.56
29274|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 240 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.9||||1.9||1.31|0.56
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AARP [1000]|AARP [100000]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AETNA [1015]|AETNA [101529]|4.93||||4.93|2.17|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.93||||4.93|1.46|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|4.93||||4.93|2.32|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.93||||4.93|2.47|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.93||||4.93|2.47|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.93||||4.93|3.11|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.93||||4.93|1.46|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|4.93||||4.93|2.71|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.93||||4.93|3.4|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.93||||4.93|2.47|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.93||||4.93|2.17|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.93||||4.93|1.46|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.93||||4.93|2.17|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.93||||4.93|1.46|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.93||||4.93|1.46|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.93||||4.93|3.4|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.93||||4.93|1.46|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|Self-pay|Self-pay|4.93||||4.93|1.73|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.93||||4.93|1.46|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.93||||4.93|1.46|3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.93||||4.93||3.4|1.46
29276|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM CD 300 MG CAPSULE,EXTENDED RELEASE 24 HR|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.93||||4.93||3.4|1.46
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|AARP [1000]|AARP [100000]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|AETNA [1015]|AETNA [101529]|58||||58|19.18|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58||||58|17.2|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|58||||58|27.26|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58||||58|0|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58||||58|29|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58||||58|36.54|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58||||58|17.2|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|58||||58|31.9|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|58||||58|40.02|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58||||58|14.39|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58||||58|19.18|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58||||58|17.2|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58||||58|19.18|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58||||58|17.2|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|58||||58|17.2|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|58||||58|40.02|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58||||58|17.2|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|Self-pay|Self-pay|58||||58|20.3|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58||||58|17.2|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58||||58|17.2|40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58||||58||40.02|14.39
2931|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ESTRADIOL VALERATE 20 MG/ML INTRAMUSCULAR OIL|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58||||58||40.02|14.39
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|9913.8||||9913.8|7438.49|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9913.8||||9913.8|2939.44|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|BCBS [1155]|BCBS UTHCT [115568]|9913.8||||9913.8|4659.49|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9913.8||||9913.8|0|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9913.8||||9913.8|4956.9|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9913.8||||9913.8|6245.69|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9913.8||||9913.8|2939.44|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA GWH [126023]|9913.8||||9913.8|4956.9|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|9913.8||||9913.8|6840.52|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9913.8||||9913.8|3635.26|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9913.8||||9913.8|7438.49|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9913.8||||9913.8|2939.44|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9913.8||||9913.8|7438.49|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9913.8||||9913.8|2939.44|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|9913.8||||9913.8|2939.44|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|9913.8||||9913.8|6840.52|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9913.8||||9913.8|2939.44|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|9913.8||||9913.8|3469.83|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9913.8||||9913.8|2939.44|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9913.8||||9913.8|2939.44|7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9913.8||||9913.8||7438.49|2939.44
29313|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CROTALIDAE POLYVAL IMMUNE FAB SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9913.8||||9913.8||7438.49|2939.44
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|24.8||||24.8|5.86|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.8||||24.8|7.35|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|24.8||||24.8|11.66|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.8||||24.8|0|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.8||||24.8|12.4|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.8||||24.8|15.62|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.8||||24.8|7.35|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|24.8||||24.8|13.64|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.8||||24.8|17.11|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.8||||24.8|4.31|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.8||||24.8|5.86|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.8||||24.8|7.35|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.8||||24.8|5.86|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.8||||24.8|7.35|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.8||||24.8|7.35|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.8||||24.8|17.11|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.8||||24.8|7.35|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|Self-pay|Self-pay|24.8||||24.8|8.68|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.8||||24.8|7.35|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.8||||24.8|7.35|17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.8||||24.8||17.11|4.31
29335|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPRANOLOL 1 MG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.8||||24.8||17.11|4.31
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.22||||19.22|8.48|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.22||||19.22|5.7|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|19.22||||19.22|9.03|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.22||||19.22|9.61|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.22||||19.22|9.61|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.22||||19.22|12.11|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.22||||19.22|5.7|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|19.22||||19.22|10.57|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.22||||19.22|13.26|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.22||||19.22|9.61|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.22||||19.22|8.48|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.22||||19.22|5.7|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.22||||19.22|8.48|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.22||||19.22|5.7|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.22||||19.22|5.7|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.22||||19.22|13.26|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.22||||19.22|5.7|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|Self-pay|Self-pay|19.22||||19.22|6.73|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.22||||19.22|5.7|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.22||||19.22|5.7|13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.22||||19.22||13.26|5.7
2938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 1.25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.22||||19.22||13.26|5.7
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AARP [1000]|AARP [100000]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AETNA [1015]|AETNA [101529]|1193.5||||1193.5|444|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1193.5||||1193.5|353.87|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|BCBS [1155]|BCBS UTHCT [115568]|1193.5||||1193.5|560.95|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1193.5||||1193.5|0|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1193.5||||1193.5|596.75|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1193.5||||1193.5|751.91|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1193.5||||1193.5|353.87|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|CIGNA [1260]|CIGNA GWH [126023]|1193.5||||1193.5|596.75|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1193.5||||1193.5|823.52|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1193.5||||1193.5|0.56|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1193.5||||1193.5|444|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1193.5||||1193.5|353.87|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1193.5||||1193.5|444|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1193.5||||1193.5|353.87|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|1193.5||||1193.5|353.87|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1193.5||||1193.5|823.52|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1193.5||||1193.5|353.87|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|Self-pay|Self-pay|1193.5||||1193.5|417.72|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1193.5||||1193.5|353.87|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1193.5||||1193.5|353.87|823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1193.5||||1193.5||823.52|0.56
29396|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BIVALIRUDIN 250 MG INTRAVENOUS POWDER FOR SOLUTION|250 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1193.5||||1193.5||823.52|0.56
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|AARP [1000]|AARP [100000]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|AETNA [1015]|AETNA [101529]|108.6||||108.6|47.89|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.6||||108.6|32.2|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|BCBS [1155]|BCBS UTHCT [115568]|108.6||||108.6|51.04|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.6||||108.6|54.3|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.6||||108.6|54.3|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.6||||108.6|68.42|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.6||||108.6|32.2|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|CIGNA [1260]|CIGNA GWH [126023]|108.6||||108.6|59.73|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|108.6||||108.6|74.93|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|108.6||||108.6|54.3|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.6||||108.6|47.89|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.6||||108.6|32.2|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.6||||108.6|47.89|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.6||||108.6|32.2|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|108.6||||108.6|32.2|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|108.6||||108.6|74.93|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.6||||108.6|32.2|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|Self-pay|Self-pay|108.6||||108.6|38.01|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|108.6||||108.6|32.2|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.6||||108.6|32.2|74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.6||||108.6||74.93|32.2
2951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHYL CHLORIDE 100 % TOPICAL SPRAY|116 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.6||||108.6||74.93|32.2
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.89||||1.89|0.83|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.89||||1.89|0.56|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.89||||1.89|0.89|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.89||||1.89|0.95|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.89||||1.89|0.95|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.89||||1.89|1.19|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.89||||1.89|0.56|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.89||||1.89|1.04|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.89||||1.89|1.3|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.89||||1.89|0.95|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.89||||1.89|0.83|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.89||||1.89|0.56|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.89||||1.89|0.83|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.89||||1.89|0.56|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.89||||1.89|0.56|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.89||||1.89|1.3|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.89||||1.89|0.56|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|1.89||||1.89|0.66|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.89||||1.89|0.56|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.89||||1.89|0.56|1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.89||||1.89||1.3|0.56
29531|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 15 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.89||||1.89||1.3|0.56
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AARP [1000]|AARP [100000]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AETNA [1015]|AETNA [101529]|2.46||||2.46|1.08|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.46||||2.46|0.73|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BCBS UTHCT [115568]|2.46||||2.46|1.16|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.46||||2.46|1.23|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.46||||2.46|1.23|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.46||||2.46|1.55|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.46||||2.46|0.73|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|CIGNA [1260]|CIGNA GWH [126023]|2.46||||2.46|1.35|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.46||||2.46|1.7|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.46||||2.46|1.23|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.46||||2.46|1.08|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.46||||2.46|0.73|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.46||||2.46|1.08|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.46||||2.46|0.73|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.46||||2.46|0.73|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.46||||2.46|1.7|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.46||||2.46|0.73|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|Self-pay|Self-pay|2.46||||2.46|0.86|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.46||||2.46|0.73|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.46||||2.46|0.73|1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.46||||2.46||1.7|0.73
29676|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.65 % NASAL SPRAY AEROSOL|44 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.46||||2.46||1.7|0.73
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|14.96||||14.96|6.6|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.96||||14.96|4.44|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|14.96||||14.96|7.03|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.96||||14.96|7.48|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.96||||14.96|7.48|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.96||||14.96|9.42|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.96||||14.96|4.44|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|14.96||||14.96|8.23|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|14.96||||14.96|10.32|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.96||||14.96|7.48|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.96||||14.96|6.6|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.96||||14.96|4.44|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.96||||14.96|6.6|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.96||||14.96|4.44|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.96||||14.96|4.44|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|14.96||||14.96|10.32|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.96||||14.96|4.44|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|Self-pay|Self-pay|14.96||||14.96|5.24|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.96||||14.96|4.44|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.96||||14.96|4.44|10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.96||||14.96||10.32|4.44
29778|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 20 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.96||||14.96||10.32|4.44
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.59||||8.59|3.79|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.59||||8.59|2.55|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|8.59||||8.59|4.04|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.59||||8.59|4.3|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.59||||8.59|4.3|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.59||||8.59|5.41|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.59||||8.59|2.55|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|8.59||||8.59|4.72|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.59||||8.59|5.93|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.59||||8.59|4.3|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.59||||8.59|3.79|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.59||||8.59|2.55|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.59||||8.59|3.79|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.59||||8.59|2.55|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.59||||8.59|2.55|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.59||||8.59|5.93|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.59||||8.59|2.55|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|Self-pay|Self-pay|8.59||||8.59|3.01|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.59||||8.59|2.55|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.59||||8.59|2.55|5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.59||||8.59||5.93|2.55
29779|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 40 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.59||||8.59|3.79|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.59||||8.59|2.55|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|8.59||||8.59|4.04|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.59||||8.59|4.3|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.59||||8.59|4.3|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.59||||8.59|5.41|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.59||||8.59|2.55|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|8.59||||8.59|4.72|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.59||||8.59|5.93|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.59||||8.59|4.3|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.59||||8.59|3.79|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.59||||8.59|2.55|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.59||||8.59|3.79|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.59||||8.59|2.55|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.59||||8.59|2.55|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.59||||8.59|5.93|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.59||||8.59|2.55|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|Self-pay|Self-pay|8.59||||8.59|3.01|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.59||||8.59|2.55|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.59||||8.59|2.55|5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.59||||8.59||5.93|2.55
29780|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 60 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.59||||8.59|3.79|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.59||||8.59|2.55|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|8.59||||8.59|4.04|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.59||||8.59|4.3|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.59||||8.59|4.3|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.59||||8.59|5.41|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.59||||8.59|2.55|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|8.59||||8.59|4.72|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.59||||8.59|5.93|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.59||||8.59|4.3|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.59||||8.59|3.79|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.59||||8.59|2.55|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.59||||8.59|3.79|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.59||||8.59|2.55|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.59||||8.59|2.55|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.59||||8.59|5.93|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.59||||8.59|2.55|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|Self-pay|Self-pay|8.59||||8.59|3.01|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.59||||8.59|2.55|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.59||||8.59|2.55|5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.59||||8.59||5.93|2.55
29781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZIPRASIDONE 80 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.59||||8.59||5.93|2.55
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|AARP [1000]|AARP [100000]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|AETNA [1015]|AETNA [101529]|1450.03||||1450.03|639.46|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1450.03||||1450.03|429.93|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|BCBS [1155]|BCBS UTHCT [115568]|1450.03||||1450.03|681.51|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1450.03||||1450.03|725.02|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1450.03||||1450.03|725.02|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1450.03||||1450.03|913.52|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1450.03||||1450.03|429.93|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|CIGNA [1260]|CIGNA GWH [126023]|1450.03||||1450.03|797.52|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1450.03||||1450.03|1000.52|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1450.03||||1450.03|725.02|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1450.03||||1450.03|639.46|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1450.03||||1450.03|429.93|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1450.03||||1450.03|639.46|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1450.03||||1450.03|429.93|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1450.03||||1450.03|429.93|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1450.03||||1450.03|1000.52|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1450.03||||1450.03|429.93|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|Self-pay|Self-pay|1450.03||||1450.03|507.51|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1450.03||||1450.03|429.93|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1450.03||||1450.03|429.93|1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1450.03||||1450.03||1000.52|429.93
29805|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 2,500 MG/250 ML (10 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1450.03||||1450.03||1000.52|429.93
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|2.72||||2.72|1.2|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.72||||2.72|0.81|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.72||||2.72|1.28|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.72||||2.72|1.36|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.72||||2.72|1.36|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.72||||2.72|1.71|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.72||||2.72|0.81|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.72||||2.72|1.5|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.72||||2.72|1.88|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.72||||2.72|1.36|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.72||||2.72|1.2|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.72||||2.72|0.81|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.72||||2.72|1.2|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.72||||2.72|0.81|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.72||||2.72|0.81|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.72||||2.72|1.88|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.72||||2.72|0.81|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|2.72||||2.72|0.95|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.72||||2.72|0.81|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.72||||2.72|0.81|1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.72||||2.72||1.88|0.81
29858|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.72||||2.72||1.88|0.81
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.8||||0.8|0.35|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.8||||0.8|0.24|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.8||||0.8|0.38|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.8||||0.8|0.4|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.8||||0.8|0.4|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.8||||0.8|0.5|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.8||||0.8|0.24|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.8||||0.8|0.44|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.8||||0.8|0.55|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.8||||0.8|0.4|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.8||||0.8|0.35|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.8||||0.8|0.24|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.8||||0.8|0.35|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.8||||0.8|0.24|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.8||||0.8|0.24|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.8||||0.8|0.55|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.8||||0.8|0.24|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.8||||0.8|0.28|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.8||||0.8|0.24|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.8||||0.8|0.24|0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.8||||0.8||0.55|0.24
29967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 7.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.8||||0.8||0.55|0.24
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|3.02||||3.02|1.33|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.02||||3.02|0.9|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.02||||3.02|1.42|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.02||||3.02|1.51|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.02||||3.02|1.51|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.02||||3.02|1.9|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.02||||3.02|0.9|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.02||||3.02|1.66|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.02||||3.02|2.08|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.02||||3.02|1.51|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.02||||3.02|1.33|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.02||||3.02|0.9|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.02||||3.02|1.33|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.02||||3.02|0.9|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.02||||3.02|0.9|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.02||||3.02|2.08|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.02||||3.02|0.9|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|3.02||||3.02|1.06|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.02||||3.02|0.9|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.02||||3.02|0.9|2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.02||||3.02||2.08|0.9
30070|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.02||||3.02||2.08|0.9
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AARP [1000]|AARP [100000]|163||||163|13.56|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163||||163|9.81|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AETNA [1015]|AETNA [101529]|163||||163|13.27|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163||||163|8.16|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163||||163|9.71|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163||||163|9.71|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BCBS UTHCT [115568]|163||||163|76.61|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163||||163|14.63|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163||||163|81.5|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163||||163|102.69|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163||||163|8.16|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163||||163|9.71|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|CIGNA [1260]|CIGNA GWH [126023]|163||||163|18.13|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163||||163|112.47|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|163||||163|12.14|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163||||163|9.71|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163||||163|13.27|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163||||163|8.16|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163||||163|9.71|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163||||163|13.27|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163||||163|8.16|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|163||||163|8.16|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163||||163|112.47|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163||||163|8.16|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|Self-pay|Self-pay|163||||163|57.05|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|163||||163|8.16|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163||||163|8.16|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163||||163|13.56|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|163||||163|9.71|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|163||||163|9.71|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163||||163|13.56|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163||||163|9.71|112.47|8.16
30083036|EAP|0300 - LABORATORY-GENERAL|HC HEMOGLOBIN GLYCOSYLATED (POCT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163||||163|19.42|112.47|8.16
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AARP [1000]|AARP [100000]|340||||340|20.43|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|340||||340|136.61|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AETNA [1015]|AETNA [101529]|340||||340|54.38|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|340||||340|100.81|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|340||||340|135.26|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|340||||340|135.26|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BCBS UTHCT [115568]|340||||340|159.8|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|340||||340|157.6|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|340||||340|170|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|340||||340|214.2|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|340||||340|100.81|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|340||||340|135.26|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|CIGNA [1260]|CIGNA GWH [126023]|340||||340|18.42|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|340||||340|234.6|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|340||||340|186.45|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|340||||340|144.86|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|340||||340|54.38|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|340||||340|100.81|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|340||||340|135.26|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|340||||340|54.38|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|340||||340|100.81|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|340||||340|100.81|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|340||||340|234.6|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|340||||340|100.81|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|Self-pay|Self-pay|340||||340|119|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|340||||340|100.81|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|340||||340|100.81|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|340||||340|20.43|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|340||||340|135.26|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|340||||340|135.26|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|340||||340|20.43|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|340||||340|135.26|270.52|18.42
30086922|EAP|0300 - LABORATORY-GENERAL|HC CROSSMATCH ANTIGLOB 1 UNIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|340||||340|270.52|270.52|18.42
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AARP [1000]|AARP [100000]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AETNA [1015]|AETNA [101529]|98||||98|43.22|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|98||||98|29.06|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS [1155]|BCBS UTHCT [115568]|98||||98|46.06|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|98||||98|7.44|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|98||||98|49|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|98||||98|61.74|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|98||||98|29.06|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|CIGNA [1260]|CIGNA GWH [126023]|98||||98|53.9|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|98||||98|67.62|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|98||||98|49|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|98||||98|43.22|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|98||||98|29.06|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|98||||98|43.22|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|98||||98|29.06|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|98||||98|29.06|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|98||||98|67.62|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|98||||98|29.06|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|Self-pay|Self-pay|98||||98|34.3|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|98||||98|29.06|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|98||||98|29.06|67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|98||||98||67.62|7.44
30099001|EAP|0300 - LABORATORY-GENERAL|HC CLIENT PROCESSING SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|98||||98||67.62|7.44
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AARP [1000]|AARP [100000]|188||||188|25.7|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|188||||188|19.5|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AETNA [1015]|AETNA [101529]|188||||188|26.42|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|188||||188|55.74|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|188||||188|19.31|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|188||||188|19.31|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|188||||188|88.36|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|188||||188|27.71|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|188||||188|94|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|188||||188|118.44|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|188||||188|55.74|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|188||||188|19.31|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|188||||188|103.4|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|188||||188|129.72|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|188||||188|24.14|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|188||||188|19.31|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|188||||188|26.42|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|188||||188|55.74|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|188||||188|19.31|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|188||||188|26.42|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|188||||188|55.74|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|188||||188|55.74|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|188||||188|129.72|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|188||||188|55.74|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|Self-pay|Self-pay|188||||188|65.8|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|188||||188|55.74|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|188||||188|55.74|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|188||||188|25.7|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|188||||188|19.31|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|188||||188|19.31|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|188||||188|25.7|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|188||||188|19.31|129.72|19.31
30100103|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATIC (PSA) SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|188||||188|38.62|129.72|19.31
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|AARP [1000]|AARP [100000]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|AETNA [1015]|AETNA [101529]|255||||255|26.76|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|255||||255|75.61|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|255||||255|119.85|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|255||||255|23.88|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|255||||255|127.5|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|255||||255|160.65|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|255||||255|75.61|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|255||||255|140.25|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|255||||255|175.95|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|255||||255|24.46|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|255||||255|26.76|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|255||||255|75.61|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|255||||255|26.76|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|255||||255|75.61|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|255||||255|75.61|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|255||||255|175.95|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|255||||255|75.61|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|Self-pay|Self-pay|255||||255|89.25|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|255||||255|75.61|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|255||||255|75.61|175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|255||||255||175.95|23.88
30100432|EAP|0301 - LABORATORY-CHEMISTRY|HC EIA HIV-1/HIV-2 SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|255||||255||175.95|23.88
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|AARP [1000]|AARP [100000]|343.29||||343.29|79.94|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|343.29||||343.29|115.57|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|AETNA [1015]|AETNA [101529]|343.29||||343.29|156.55|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|343.29||||343.29|101.79|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|343.29||||343.29|114.43|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|343.29||||343.29|114.43|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|BCBS [1155]|BCBS UTHCT [115568]|343.29||||343.29|161.35|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|343.29||||343.29|139.6|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|343.29||||343.29|171.65|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|343.29||||343.29|216.27|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|343.29||||343.29|101.79|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|343.29||||343.29|114.43|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|CIGNA [1260]|CIGNA GWH [126023]|343.29||||343.29|188.81|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|343.29||||343.29|236.87|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|343.29||||343.29|143.04|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|343.29||||343.29|114.43|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|343.29||||343.29|156.55|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|343.29||||343.29|101.79|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|343.29||||343.29|114.43|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|343.29||||343.29|156.55|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|343.29||||343.29|101.79|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|343.29||||343.29|101.79|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|343.29||||343.29|236.87|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|343.29||||343.29|101.79|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|Self-pay|Self-pay|343.29||||343.29|120.15|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|343.29||||343.29|101.79|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|343.29||||343.29|101.79|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|343.29||||343.29|79.94|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|343.29||||343.29|114.43|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|343.29||||343.29|114.43|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|343.29||||343.29|79.94|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|343.29||||343.29|114.43|236.87|79.94
30100480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|343.29||||343.29|228.86|236.87|79.94
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|AARP [1000]|AARP [100000]|72||||72|72|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72||||72|115.57|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|AETNA [1015]|AETNA [101529]|72||||72|72|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72||||72|21.35|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72||||72|114.43|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72||||72|114.43|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|BCBS [1155]|BCBS UTHCT [115568]|72||||72|33.84|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72||||72|72|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72||||72|36|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72||||72|45.36|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72||||72|21.35|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72||||72|114.43|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|CIGNA [1260]|CIGNA GWH [126023]|72||||72|39.6|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|72||||72|49.68|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|72||||72|143.04|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72||||72|114.43|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72||||72|72|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72||||72|21.35|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72||||72|114.43|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72||||72|72|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72||||72|21.35|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|72||||72|21.35|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|72||||72|49.68|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72||||72|21.35|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|Self-pay|Self-pay|72||||72|25.2|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|72||||72|21.35|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72||||72|21.35|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72||||72|72|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|72||||72|114.43|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|72||||72|114.43|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72||||72|72|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72||||72|114.43|228.86|21.35
30110480|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST DEF 1-7 CLASSES NMMI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72||||72|228.86|228.86|21.35
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AARP [1000]|AARP [100000]|233||||233|11.83|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|233||||233|8.54|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AETNA [1015]|AETNA [101529]|233||||233|11.57|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|233||||233|7.11|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|233||||233|8.46|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|233||||233|8.46|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BCBS UTHCT [115568]|233||||233|109.51|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|233||||233|12.74|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|233||||233|116.5|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|233||||233|146.79|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|233||||233|7.11|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|233||||233|8.46|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|CIGNA [1260]|CIGNA GWH [126023]|233||||233|9.92|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|233||||233|160.77|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|233||||233|10.58|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|233||||233|8.46|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|233||||233|11.57|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|233||||233|7.11|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|233||||233|8.46|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|233||||233|11.57|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|233||||233|7.11|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|233||||233|7.11|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|233||||233|160.77|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|233||||233|7.11|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|Self-pay|Self-pay|233||||233|81.55|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|233||||233|7.11|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|233||||233|7.11|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|233||||233|11.83|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|233||||233|8.46|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|233||||233|8.46|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|233||||233|11.83|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|233||||233|8.46|160.77|7.11
30180048|EAP|0301 - LABORATORY-CHEMISTRY|HC BASIC METABOLIC PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|233||||233|16.92|160.77|7.11
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|AARP [1000]|AARP [100000]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|AETNA [1015]|AETNA [101529]|610||||610|65.98|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|610||||610|180.87|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|BCBS [1155]|BCBS UTHCT [115568]|610||||610|286.7|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|610||||610|42.91|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|610||||610|305|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|610||||610|384.3|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|610||||610|180.87|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|CIGNA [1260]|CIGNA GWH [126023]|610||||610|32.3|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|610||||610|420.9|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|610||||610|43.91|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|610||||610|65.98|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|610||||610|180.87|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|610||||610|65.98|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|610||||610|180.87|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|610||||610|180.87|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|610||||610|420.9|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|610||||610|180.87|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|Self-pay|Self-pay|610||||610|213.5|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|610||||610|180.87|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|610||||610|180.87|420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|610||||610||420.9|32.3
30180050|EAP|0301 - LABORATORY-CHEMISTRY|HC GENERAL HEALTH PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|610||||610||420.9|32.3
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AARP [1000]|AARP [100000]|231||||231|9.8|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|231||||231|7.08|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AETNA [1015]|AETNA [101529]|231||||231|9.6|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|231||||231|5.89|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|231||||231|7.01|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|231||||231|7.01|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BCBS UTHCT [115568]|231||||231|108.57|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|231||||231|10.57|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|231||||231|115.5|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|231||||231|145.53|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|231||||231|5.89|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|231||||231|7.01|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|CIGNA [1260]|CIGNA GWH [126023]|231||||231|8.21|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|231||||231|159.39|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|231||||231|8.76|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|231||||231|7.01|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|231||||231|9.6|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|231||||231|5.89|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|231||||231|7.01|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|231||||231|9.6|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|231||||231|5.89|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|231||||231|5.89|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|231||||231|159.39|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|231||||231|5.89|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|Self-pay|Self-pay|231||||231|80.85|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|231||||231|5.89|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|231||||231|5.89|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|231||||231|9.8|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|231||||231|7.01|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|231||||231|7.01|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|231||||231|9.8|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|231||||231|7.01|159.39|5.89
30180051|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROLYTE PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|231||||231|14.02|159.39|5.89
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AARP [1000]|AARP [100000]|314||||314|14.77|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|314||||314|10.67|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AETNA [1015]|AETNA [101529]|314||||314|14.45|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|314||||314|8.87|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|314||||314|10.56|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|314||||314|10.56|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BCBS UTHCT [115568]|314||||314|147.58|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|314||||314|15.91|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|314||||314|157|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|314||||314|197.82|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|314||||314|8.87|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|314||||314|10.56|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|CIGNA [1260]|CIGNA GWH [126023]|314||||314|12.18|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|314||||314|216.66|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|314||||314|13.2|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|314||||314|10.56|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|314||||314|14.45|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|314||||314|8.87|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|314||||314|10.56|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|314||||314|14.45|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|314||||314|8.87|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|314||||314|8.87|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|314||||314|216.66|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|314||||314|8.87|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|Self-pay|Self-pay|314||||314|109.9|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|314||||314|8.87|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|314||||314|8.87|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|314||||314|14.77|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|314||||314|10.56|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|314||||314|10.56|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|314||||314|14.77|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|314||||314|10.56|216.66|8.87
30180053|EAP|0301 - LABORATORY-CHEMISTRY|HC COMPREHENSIVE METABOLIC PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|314||||314|21.12|216.66|8.87
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AARP [1000]|AARP [100000]|236||||236|18.72|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|236||||236|13.52|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AETNA [1015]|AETNA [101529]|236||||236|18.31|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|236||||236|11.25|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|236||||236|13.39|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|236||||236|13.39|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BCBS UTHCT [115568]|236||||236|110.92|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|236||||236|20.17|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|236||||236|118|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|236||||236|148.68|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|236||||236|11.25|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|236||||236|13.39|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|CIGNA [1260]|CIGNA GWH [126023]|236||||236|18.7|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|236||||236|162.84|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|236||||236|16.74|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|236||||236|13.39|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|236||||236|18.31|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|236||||236|11.25|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|236||||236|13.39|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|236||||236|18.31|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|236||||236|11.25|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|236||||236|11.25|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|236||||236|162.84|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|236||||236|11.25|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|Self-pay|Self-pay|236||||236|82.6|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|236||||236|11.25|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|236||||236|11.25|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|236||||236|18.72|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|236||||236|13.39|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|236||||236|13.39|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|236||||236|18.72|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|236||||236|13.39|162.84|11.25
30180061|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPID PROFILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|236||||236|26.78|162.84|11.25
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AARP [1000]|AARP [100000]|290||||290|12.13|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|290||||290|8.77|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AETNA [1015]|AETNA [101529]|290||||290|11.88|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|290||||290|7.29|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|290||||290|8.68|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|290||||290|8.68|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BCBS UTHCT [115568]|290||||290|136.3|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|290||||290|13.08|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|290||||290|145|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|290||||290|182.7|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|290||||290|7.29|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|290||||290|8.68|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|CIGNA [1260]|CIGNA GWH [126023]|290||||290|10.2|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|290||||290|200.1|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|290||||290|10.85|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|290||||290|8.68|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|290||||290|11.88|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|290||||290|7.29|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|290||||290|8.68|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|290||||290|11.88|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|290||||290|7.29|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|290||||290|7.29|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|290||||290|200.1|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|290||||290|7.29|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|Self-pay|Self-pay|290||||290|101.5|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|290||||290|7.29|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|290||||290|7.29|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|290||||290|12.13|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|290||||290|8.68|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|290||||290|8.68|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|290||||290|12.13|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|290||||290|8.68|200.1|7.29
30180069|EAP|0301 - LABORATORY-CHEMISTRY|HC RENAL FUNCTION PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|290||||290|17.36|200.1|7.29
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AARP [1000]|AARP [100000]|735||||735|66.54|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|735||||735|48.11|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AETNA [1015]|AETNA [101529]|735||||735|65.16|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|735||||735|40.01|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|735||||735|47.63|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|735||||735|47.63|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BCBS UTHCT [115568]|735||||735|345.45|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|735||||735|71.75|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|735||||735|367.5|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|735||||735|463.05|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|735||||735|40.01|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|735||||735|47.63|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|CIGNA [1260]|CIGNA GWH [126023]|735||||735|52.69|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|735||||735|507.15|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|735||||735|59.54|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|735||||735|47.63|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|735||||735|65.16|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|735||||735|40.01|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|735||||735|47.63|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|735||||735|65.16|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|735||||735|40.01|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|735||||735|40.01|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|735||||735|507.15|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|735||||735|40.01|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|Self-pay|Self-pay|735||||735|257.25|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|735||||735|40.01|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|735||||735|40.01|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|735||||735|66.54|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|735||||735|47.63|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|735||||735|47.63|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|735||||735|66.54|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|735||||735|47.63|507.15|40.01
30180074|EAP|0301 - LABORATORY-CHEMISTRY|HC ACUTE HEPATITIS PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|735||||735|95.26|507.15|40.01
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AARP [1000]|AARP [100000]|246||||246|11.42|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|246||||246|8.25|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AETNA [1015]|AETNA [101529]|246||||246|11.18|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|246||||246|6.86|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|246||||246|8.17|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|246||||246|8.17|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BCBS UTHCT [115568]|246||||246|115.62|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|246||||246|12.31|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|246||||246|123|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|246||||246|154.98|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|246||||246|6.86|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|246||||246|8.17|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|CIGNA [1260]|CIGNA GWH [126023]|246||||246|9.64|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|246||||246|169.74|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|246||||246|10.21|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|246||||246|8.17|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|246||||246|11.18|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|246||||246|6.86|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|246||||246|8.17|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|246||||246|11.18|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|246||||246|6.86|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|246||||246|6.86|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|246||||246|169.74|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|246||||246|6.86|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|Self-pay|Self-pay|246||||246|86.1|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|246||||246|6.86|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|246||||246|6.86|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|246||||246|11.42|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|246||||246|8.17|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|246||||246|8.17|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|246||||246|11.42|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|246||||246|8.17|169.74|6.86
30180076|EAP|0301 - LABORATORY-CHEMISTRY|HC HEPATIC FUNCTION PANEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|246||||246|16.34|169.74|6.86
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|AARP [1000]|AARP [100000]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|AETNA [1015]|AETNA [101529]|244||||244|25.49|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|BCBS [1155]|BCBS UTHCT [115568]|244||||244|114.68|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244||||244|22.74|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244||||244|122|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244||||244|153.72|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|CIGNA [1260]|CIGNA GWH [126023]|244||||244|134.2|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|244||||244|168.36|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|244||||244|23.3|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244||||244|25.49|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244||||244|25.49|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|244||||244|168.36|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|Self-pay|Self-pay|244||||244|85.4|168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244||||244||168.36|22.74
30180143|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETAMINOPHEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244||||244||168.36|22.74
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AARP [1000]|AARP [100000]|113||||113|21.06|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|113||||113|15.23|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AETNA [1015]|AETNA [101529]|113||||113|20.64|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|113||||113|12.67|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|113||||113|15.08|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|113||||113|15.08|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BCBS UTHCT [115568]|113||||113|53.11|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|113||||113|22.7|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|113||||113|56.5|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|113||||113|71.19|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|113||||113|12.67|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|113||||113|15.08|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|CIGNA [1260]|CIGNA GWH [126023]|113||||113|17.57|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|113||||113|77.97|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|113||||113|18.85|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|113||||113|15.08|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|113||||113|20.64|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|113||||113|12.67|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|113||||113|15.08|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|113||||113|20.64|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|113||||113|12.67|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|113||||113|12.67|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|113||||113|77.97|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|113||||113|12.67|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|Self-pay|Self-pay|113||||113|39.55|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|113||||113|12.67|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|113||||113|12.67|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|113||||113|21.06|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|113||||113|15.08|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|113||||113|15.08|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|113||||113|21.06|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|113||||113|15.08|77.97|12.67
30180150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMIKACIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|113||||113|30.16|77.97|12.67
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AARP [1000]|AARP [100000]|333||||333|20.34|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|333||||333|14.72|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AETNA [1015]|AETNA [101529]|333||||333|19.92|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|333||||333|12.24|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|333||||333|14.57|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|333||||333|14.57|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS [1155]|BCBS UTHCT [115568]|333||||333|156.51|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|333||||333|21.94|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|333||||333|166.5|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|333||||333|209.79|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|333||||333|12.24|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|333||||333|14.57|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|CIGNA [1260]|CIGNA GWH [126023]|333||||333|16.99|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|333||||333|229.77|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|333||||333|18.21|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|333||||333|14.57|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|333||||333|19.92|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|333||||333|12.24|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|333||||333|14.57|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|333||||333|19.92|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|333||||333|12.24|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|333||||333|12.24|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|333||||333|229.77|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|333||||333|12.24|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|Self-pay|Self-pay|333||||333|116.55|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|333||||333|12.24|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|333||||333|12.24|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|333||||333|20.34|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|333||||333|14.57|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|333||||333|14.57|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|333||||333|20.34|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|333||||333|14.57|229.77|12.24
30180156|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBAMAZEPINE (TEGRETOL)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|333||||333|29.14|229.77|12.24
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AARP [1000]|AARP [100000]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AETNA [1015]|AETNA [101529]|335||||335|24.7|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BCBS UTHCT [115568]|335||||335|157.45|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|335||||335|27.18|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|335||||335|167.5|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|335||||335|211.05|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|CIGNA [1260]|CIGNA GWH [126023]|335||||335|20.96|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|335||||335|231.15|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|335||||335|22.56|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|335||||335|24.7|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|335||||335|24.7|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|335||||335|231.15|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|Self-pay|Self-pay|335||||335|117.25|231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|335||||335||231.15|20.96
30180158|EAP|0301 - LABORATORY-CHEMISTRY|HC CYCLOSPORINE (SANDIMMUNE)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|335||||335||231.15|20.96
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|AARP [1000]|AARP [100000]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|AETNA [1015]|AETNA [101529]|258||||258|27.58|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|BCBS [1155]|BCBS UTHCT [115568]|258||||258|121.26|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258||||258|27.85|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258||||258|129|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258||||258|162.54|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|CIGNA [1260]|CIGNA GWH [126023]|258||||258|141.9|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|258||||258|178.02|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258||||258|25.19|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258||||258|27.58|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258||||258|27.58|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|258||||258|178.02|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|Self-pay|Self-pay|258||||258|90.3|178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258||||258||178.02|25.19
30180159|EAP|0301 - LABORATORY-CHEMISTRY|HC THERAPEUTIC DRUG LEVELS CLOZAPINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258||||258||178.02|25.19
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AARP [1000]|AARP [100000]|204||||204|18.55|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|13.41|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AETNA [1015]|AETNA [101529]|204||||204|18.17|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|11.16|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|13.28|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|13.28|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|20|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|11.16|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|13.28|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|15.29|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|16.6|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|13.28|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|18.17|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|11.16|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|13.28|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|18.17|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|11.16|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|11.16|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|11.16|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|Self-pay|Self-pay|204||||204|71.4|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|11.16|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|11.16|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|18.55|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|13.28|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|13.28|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|18.55|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|13.28|140.76|11.16
30180162|EAP|0301 - LABORATORY-CHEMISTRY|HC DIGOXIN TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|26.56|140.76|11.16
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AARP [1000]|AARP [100000]|211||||211|18.93|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|211||||211|13.68|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AETNA [1015]|AETNA [101529]|211||||211|18.53|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|211||||211|11.37|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|211||||211|13.54|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|211||||211|13.54|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|211||||211|99.17|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|211||||211|20.4|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|211||||211|105.5|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|211||||211|132.93|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|211||||211|11.37|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|211||||211|13.54|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|211||||211|15.86|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|211||||211|145.59|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|211||||211|16.93|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|211||||211|13.54|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|211||||211|18.53|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|211||||211|11.37|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|211||||211|13.54|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|211||||211|18.53|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|211||||211|11.37|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|211||||211|11.37|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|211||||211|145.59|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|211||||211|11.37|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|Self-pay|Self-pay|211||||211|73.85|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|211||||211|11.37|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|211||||211|11.37|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|211||||211|18.93|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|211||||211|13.54|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|211||||211|13.54|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|211||||211|18.93|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|211||||211|13.54|145.59|11.37
30180164|EAP|0301 - LABORATORY-CHEMISTRY|HC DIPROPYLACETIC ACID(VALPROIC) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|211||||211|27.08|145.59|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|AARP [1000]|AARP [100000]|41||||41|18.44|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41||||41|13.68|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|AETNA [1015]|AETNA [101529]|41||||41|18.53|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41||||41|11.37|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41||||41|13.54|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41||||41|13.54|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|BCBS [1155]|BCBS UTHCT [115568]|41||||41|19.27|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41||||41|20.4|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41||||41|20.5|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41||||41|25.83|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41||||41|11.37|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41||||41|13.54|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|CIGNA [1260]|CIGNA GWH [126023]|41||||41|22.55|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|41||||41|28.29|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41||||41|16.93|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41||||41|13.54|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41||||41|18.53|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41||||41|11.37|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41||||41|13.54|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41||||41|18.53|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41||||41|11.37|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|41||||41|11.37|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|41||||41|28.29|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41||||41|11.37|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|Self-pay|Self-pay|41||||41|14.35|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41||||41|11.37|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41||||41|11.37|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41||||41|18.44|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41||||41|13.54|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41||||41|13.54|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41||||41|18.44|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41||||41|13.54|28.29|11.37
30180165|EAP|0301 - LABORATORY-CHEMISTRY|HC VALPROIC ACID FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41||||41|27.08|28.29|11.37
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|AARP [1000]|AARP [100000]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|AETNA [1015]|AETNA [101529]|113||||113|22.34|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|BCBS [1155]|BCBS UTHCT [115568]|113||||113|53.11|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|113||||113|24.61|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|113||||113|56.5|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|113||||113|71.19|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|CIGNA [1260]|CIGNA GWH [126023]|113||||113|18.98|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|113||||113|77.97|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|113||||113|20.46|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|113||||113|22.34|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|113||||113|22.34|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|113||||113|77.97|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|Self-pay|Self-pay|113||||113|39.55|77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|113||||113||77.97|18.98
30180168|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHOSUXIMIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AARP [1000]|AARP [100000]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AETNA [1015]|AETNA [101529]|113||||113|22.42|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BCBS UTHCT [115568]|113||||113|53.11|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|113||||113|24.67|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|113||||113|56.5|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|113||||113|71.19|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|CIGNA [1260]|CIGNA GWH [126023]|113||||113|18.98|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|113||||113|77.97|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|113||||113|20.48|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|113||||113|22.42|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|113||||113|22.42|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|113||||113|77.97|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|Self-pay|Self-pay|113||||113|39.55|77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|113||||113||77.97|18.98
30180170|EAP|0301 - LABORATORY-CHEMISTRY|HC GENTAMICIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|113||||113||77.97|18.98
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AARP [1000]|AARP [100000]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AETNA [1015]|AETNA [101529]|258||||258|29.64|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS [1155]|BCBS UTHCT [115568]|258||||258|121.26|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258||||258|26.44|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258||||258|129|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258||||258|162.54|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|CIGNA [1260]|CIGNA GWH [126023]|258||||258|141.9|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|258||||258|178.02|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258||||258|27.09|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258||||258|29.64|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258||||258|29.64|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|258||||258|178.02|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|Self-pay|Self-pay|258||||258|90.3|178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258||||258||178.02|26.44
30180171|EAP|0301 - LABORATORY-CHEMISTRY|HC GABAPENTIN (NEURONTIN)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258||||258||178.02|26.44
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|AARP [1000]|AARP [100000]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|AETNA [1015]|AETNA [101529]|63||||63|21.58|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|BCBS [1155]|BCBS UTHCT [115568]|63||||63|29.61|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63||||63|21.94|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63||||63|31.5|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63||||63|39.69|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|CIGNA [1260]|CIGNA GWH [126023]|63||||63|16.99|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63||||63|43.47|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63||||63|19.73|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63||||63|21.58|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63||||63|21.58|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63||||63|43.47|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|Self-pay|Self-pay|63||||63|22.05|43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63||||63||43.47|16.99
30180173|EAP|0301 - LABORATORY-CHEMISTRY|HC HALOPERIDOL (HALDOL)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63||||63||43.47|16.99
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AARP [1000]|AARP [100000]|258||||258|18.09|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258||||258|13.38|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AETNA [1015]|AETNA [101529]|258||||258|18.12|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258||||258|11.13|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258||||258|13.25|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258||||258|13.25|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS [1155]|BCBS UTHCT [115568]|258||||258|121.26|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258||||258|19.96|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258||||258|129|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258||||258|162.54|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258||||258|11.13|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258||||258|13.25|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|CIGNA [1260]|CIGNA GWH [126023]|258||||258|141.9|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|258||||258|178.02|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258||||258|16.56|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258||||258|13.25|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258||||258|18.12|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258||||258|11.13|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258||||258|13.25|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258||||258|18.12|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258||||258|11.13|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|258||||258|11.13|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|258||||258|178.02|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258||||258|11.13|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|Self-pay|Self-pay|258||||258|90.3|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258||||258|11.13|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258||||258|11.13|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258||||258|18.09|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258||||258|13.25|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258||||258|13.25|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258||||258|18.09|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258||||258|13.25|178.02|11.13
30180175|EAP|0301 - LABORATORY-CHEMISTRY|HC LAMOTRIGINE (LAMICTAL)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258||||258|26.5|178.02|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AARP [1000]|AARP [100000]|173||||173|18.09|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|173||||173|13.38|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AETNA [1015]|AETNA [101529]|173||||173|18.12|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|173||||173|11.13|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|173||||173|13.25|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|173||||173|13.25|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS [1155]|BCBS UTHCT [115568]|173||||173|81.31|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|173||||173|19.96|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|173||||173|86.5|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|173||||173|108.99|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|173||||173|11.13|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|173||||173|13.25|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|CIGNA [1260]|CIGNA GWH [126023]|173||||173|95.15|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|173||||173|119.37|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|173||||173|16.56|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|173||||173|13.25|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|173||||173|18.12|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|173||||173|11.13|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|173||||173|13.25|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|173||||173|18.12|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|173||||173|11.13|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|173||||173|11.13|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|173||||173|119.37|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|173||||173|11.13|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|Self-pay|Self-pay|173||||173|60.55|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|173||||173|11.13|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|173||||173|11.13|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|173||||173|18.09|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|173||||173|13.25|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|173||||173|13.25|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|173||||173|18.09|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|173||||173|13.25|119.37|11.13
30180177|EAP|0301 - LABORATORY-CHEMISTRY|HC LEVETIRACE (KEPPRA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|173||||173|26.5|119.37|11.13
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AARP [1000]|AARP [100000]|176||||176|9.24|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|176||||176|6.68|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AETNA [1015]|AETNA [101529]|176||||176|9.05|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|176||||176|5.55|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|176||||176|6.61|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|176||||176|6.61|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS [1155]|BCBS UTHCT [115568]|176||||176|82.72|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|176||||176|9.96|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|176||||176|88|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|176||||176|110.88|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|176||||176|5.55|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|176||||176|6.61|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|CIGNA [1260]|CIGNA GWH [126023]|176||||176|7.64|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|176||||176|121.44|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|176||||176|8.26|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|176||||176|6.61|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|176||||176|9.05|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|176||||176|5.55|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|176||||176|6.61|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|176||||176|9.05|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|176||||176|5.55|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|176||||176|5.55|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|176||||176|121.44|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|176||||176|5.55|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|Self-pay|Self-pay|176||||176|61.6|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|176||||176|5.55|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|176||||176|5.55|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|176||||176|9.24|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|176||||176|6.61|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|176||||176|6.61|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|176||||176|9.24|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|176||||176|6.61|121.44|5.55
30180178|EAP|0301 - LABORATORY-CHEMISTRY|HC LITHIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|176||||176|13.22|121.44|5.55
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|AARP [1000]|AARP [100000]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|AETNA [1015]|AETNA [101529]|244||||244|25.49|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|BCBS [1155]|BCBS UTHCT [115568]|244||||244|114.68|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244||||244|22.74|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244||||244|122|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244||||244|153.72|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|CIGNA [1260]|CIGNA GWH [126023]|244||||244|134.2|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|244||||244|168.36|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|244||||244|23.3|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244||||244|25.49|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244||||244|25.49|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|244||||244|168.36|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|Self-pay|Self-pay|244||||244|85.4|168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244||||244||168.36|22.74
30180179|EAP|0301 - LABORATORY-CHEMISTRY|HC SALICYLATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244||||244||168.36|22.74
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|AARP [1000]|AARP [100000]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|AETNA [1015]|AETNA [101529]|258||||258|24.7|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|BCBS [1155]|BCBS UTHCT [115568]|258||||258|121.26|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258||||258|27.18|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258||||258|129|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258||||258|162.54|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|CIGNA [1260]|CIGNA GWH [126023]|258||||258|141.9|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|258||||258|178.02|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258||||258|22.56|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258||||258|24.7|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258||||258|24.7|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|258||||258|178.02|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|Self-pay|Self-pay|258||||258|90.3|178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258||||258||178.02|22.56
30180180|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCRN QUAN MYCOPHENOLATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258||||258||178.02|22.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|AARP [1000]|AARP [100000]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|AETNA [1015]|AETNA [101529]|258||||258|18.12|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|BCBS [1155]|BCBS UTHCT [115568]|258||||258|121.26|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258||||258|19.96|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258||||258|129|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258||||258|162.54|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|CIGNA [1260]|CIGNA GWH [126023]|258||||258|141.9|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|258||||258|178.02|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258||||258|16.56|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258||||258|18.12|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258||||258|18.12|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|258||||258|178.02|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|Self-pay|Self-pay|258||||258|90.3|178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258||||258||178.02|16.56
30180183|EAP|0301 - LABORATORY-CHEMISTRY|HC OXCARBAZEPINE (TRILEPTAL) QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258||||258||178.02|16.56
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AARP [1000]|AARP [100000]|239||||239|16.01|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|239||||239|15.45|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AETNA [1015]|AETNA [101529]|239||||239|20.93|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|239||||239|12.85|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|239||||239|15.3|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|239||||239|15.3|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BCBS UTHCT [115568]|239||||239|112.33|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|239||||239|18.67|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|239||||239|119.5|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|239||||239|150.57|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|239||||239|12.85|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|239||||239|15.3|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|CIGNA [1260]|CIGNA GWH [126023]|239||||239|13.32|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|239||||239|164.91|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|239||||239|19.13|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|239||||239|15.3|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|239||||239|20.93|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|239||||239|12.85|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|239||||239|15.3|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|239||||239|20.93|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|239||||239|12.85|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|239||||239|12.85|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|239||||239|164.91|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|239||||239|12.85|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|Self-pay|Self-pay|239||||239|83.65|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|239||||239|12.85|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|239||||239|12.85|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|239||||239|16.01|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|239||||239|15.3|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|239||||239|15.3|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|239||||239|16.01|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|239||||239|15.3|164.91|12.85
30180184|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENOBARBITAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|239||||239|30.6|164.91|12.85
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AARP [1000]|AARP [100000]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AETNA [1015]|AETNA [101529]|246||||246|18.12|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BCBS UTHCT [115568]|246||||246|115.62|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|246||||246|19.96|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|246||||246|123|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|246||||246|154.98|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|CIGNA [1260]|CIGNA GWH [126023]|246||||246|15.29|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|246||||246|169.74|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|246||||246|16.56|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|246||||246|18.12|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|246||||246|18.12|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|246||||246|169.74|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|Self-pay|Self-pay|246||||246|86.1|169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|246||||246||169.74|15.29
30180185|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|246||||246||169.74|15.29
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|AARP [1000]|AARP [100000]|297||||297|19.23|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|297||||297|13.9|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|AETNA [1015]|AETNA [101529]|297||||297|18.82|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|297||||297|11.56|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|297||||297|13.76|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|297||||297|13.76|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|BCBS [1155]|BCBS UTHCT [115568]|297||||297|139.59|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|297||||297|20.73|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|297||||297|148.5|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|297||||297|187.11|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|297||||297|11.56|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|297||||297|13.76|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|CIGNA [1260]|CIGNA GWH [126023]|297||||297|15.86|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|297||||297|204.93|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|297||||297|17.2|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|297||||297|13.76|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|297||||297|18.82|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|297||||297|11.56|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|297||||297|13.76|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|297||||297|18.82|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|297||||297|11.56|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|297||||297|11.56|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|297||||297|204.93|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|297||||297|11.56|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|Self-pay|Self-pay|297||||297|103.95|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|297||||297|11.56|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|297||||297|11.56|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|297||||297|19.23|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|297||||297|13.76|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|297||||297|13.76|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|297||||297|19.23|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|297||||297|13.76|204.93|11.56
30180186|EAP|0301 - LABORATORY-CHEMISTRY|HC PHENYTOIN FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|297||||297|27.52|204.93|11.56
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|AARP [1000]|AARP [100000]|36||||36|23.18|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36|16.76|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|AETNA [1015]|AETNA [101529]|36||||36|22.7|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36|13.94|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36|16.59|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36|16.59|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|BCBS [1155]|BCBS UTHCT [115568]|36||||36|16.92|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|24.99|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|18|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|22.68|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36|13.94|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36|16.59|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|CIGNA [1260]|CIGNA GWH [126023]|36||||36|19.27|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|36||||36|20.74|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36|16.59|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|22.7|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36|13.94|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36|16.59|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|22.7|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36|13.94|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|36||||36|13.94|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36|13.94|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|Self-pay|Self-pay|36||||36|12.6|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|36||||36|13.94|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36|13.94|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36|23.18|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|36||||36|16.59|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|36||||36|16.59|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36|23.18|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36|16.59|33.18|12.6
30180188|EAP|0301 - LABORATORY-CHEMISTRY|HC PRIMIDONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36||||36|33.18|33.18|12.6
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|AARP [1000]|AARP [100000]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|AETNA [1015]|AETNA [101529]|34||||34|22.92|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|BCBS [1155]|BCBS UTHCT [115568]|34||||34|15.98|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|25.23|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|21.42|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|CIGNA [1260]|CIGNA GWH [126023]|34||||34|19.54|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34||||34|20.94|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|22.92|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|22.92|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|Self-pay|Self-pay|34||||34|11.9|25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34||25.23|11.9
30180192|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCAINAMIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34||25.23|11.9
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AARP [1000]|AARP [100000]|42||||42|19.17|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|42||||42|13.87|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AETNA [1015]|AETNA [101529]|42||||42|18.79|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42||||42|11.53|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42||||42|13.73|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|42||||42|13.73|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS [1155]|BCBS UTHCT [115568]|42||||42|19.74|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|42||||42|20.69|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|42||||42|21|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|42||||42|26.46|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|42||||42|11.53|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|42||||42|13.73|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|CIGNA [1260]|CIGNA GWH [126023]|42||||42|15.86|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|42||||42|28.98|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|42||||42|17.16|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|42||||42|13.73|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42||||42|18.79|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42||||42|11.53|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42||||42|13.73|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42||||42|18.79|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|42||||42|11.53|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|42||||42|11.53|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|42||||42|28.98|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42||||42|11.53|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|Self-pay|Self-pay|42||||42|14.7|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|42||||42|11.53|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|42||||42|11.53|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42||||42|19.17|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|42||||42|13.73|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|42||||42|13.73|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42||||42|19.17|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42||||42|13.73|28.98|11.53
30180195|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY SIROLIMUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|42||||42|27.46|28.98|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AARP [1000]|AARP [100000]|300||||300|19.17|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300|13.87|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AETNA [1015]|AETNA [101529]|300||||300|18.79|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|11.53|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300|13.73|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300|13.73|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|20.69|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|11.53|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300|13.73|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|15.86|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|17.16|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300|13.73|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|18.79|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|11.53|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300|13.73|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|18.79|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|11.53|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|11.53|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|11.53|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|Self-pay|Self-pay|300||||300|105|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|11.53|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|11.53|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|19.17|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300|13.73|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300|13.73|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|19.17|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300|13.73|207|11.53
30180197|EAP|0301 - LABORATORY-CHEMISTRY|HC TACROLIMUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300|27.46|207|11.53
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AARP [1000]|AARP [100000]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AETNA [1015]|AETNA [101529]|195||||195|19.34|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS [1155]|BCBS UTHCT [115568]|195||||195|91.65|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|195||||195|21.3|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|195||||195|97.5|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|195||||195|122.85|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|CIGNA [1260]|CIGNA GWH [126023]|195||||195|16.43|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|195||||195|134.55|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|195||||195|17.68|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|195||||195|19.34|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|195||||195|19.34|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|195||||195|134.55|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|Self-pay|Self-pay|195||||195|68.25|134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|195||||195||134.55|16.43
30180198|EAP|0301 - LABORATORY-CHEMISTRY|HC THEOPHYLLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|195||||195||134.55|16.43
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AARP [1000]|AARP [100000]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AETNA [1015]|AETNA [101529]|333||||333|22.06|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BCBS UTHCT [115568]|333||||333|156.51|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|333||||333|24.29|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|333||||333|166.5|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|333||||333|209.79|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|CIGNA [1260]|CIGNA GWH [126023]|333||||333|18.7|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|333||||333|229.77|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|333||||333|20.16|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|333||||333|22.06|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|333||||333|22.06|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|333||||333|229.77|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|Self-pay|Self-pay|333||||333|116.55|229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|333||||333||229.77|18.7
30180200|EAP|0301 - LABORATORY-CHEMISTRY|HC TOBRAMYCIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|333||||333||229.77|18.7
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|AARP [1000]|AARP [100000]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|AETNA [1015]|AETNA [101529]|34||||34|16.3|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|BCBS [1155]|BCBS UTHCT [115568]|34||||34|15.98|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|17.96|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|21.42|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|CIGNA [1260]|CIGNA GWH [126023]|34||||34|13.88|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34||||34|14.9|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|16.3|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|16.3|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|Self-pay|Self-pay|34||||34|11.9|23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34||23.46|11.9
30180201|EAP|0301 - LABORATORY-CHEMISTRY|HC TOPIRAMATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34||23.46|11.9
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AARP [1000]|AARP [100000]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AETNA [1015]|AETNA [101529]|259||||259|18.53|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BCBS UTHCT [115568]|259||||259|121.73|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|259||||259|20.4|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|259||||259|129.5|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|259||||259|163.17|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|CIGNA [1260]|CIGNA GWH [126023]|259||||259|15.86|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|259||||259|178.71|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|259||||259|16.93|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|259||||259|18.53|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|259||||259|18.53|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|259||||259|178.71|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|Self-pay|Self-pay|259||||259|90.65|178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|259||||259||178.71|15.86
30180202|EAP|0301 - LABORATORY-CHEMISTRY|HC VANCOMYCIN PEAK/TROUGH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|259||||259||178.71|15.86
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|AARP [1000]|AARP [100000]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|AETNA [1015]|AETNA [101529]|258||||258|18.12|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|BCBS [1155]|BCBS UTHCT [115568]|258||||258|121.26|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258||||258|19.96|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258||||258|129|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258||||258|162.54|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|CIGNA [1260]|CIGNA GWH [126023]|258||||258|141.9|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|258||||258|178.02|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258||||258|16.56|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258||||258|18.12|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258||||258|18.12|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|258||||258|178.02|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|Self-pay|Self-pay|258||||258|90.3|178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258||||258||178.02|16.56
30180203|EAP|0301 - LABORATORY-CHEMISTRY|HC ZONISAMIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258||||258||178.02|16.56
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|AARP [1000]|AARP [100000]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|AETNA [1015]|AETNA [101529]|356||||356|52.75|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|BCBS [1155]|BCBS UTHCT [115568]|356||||356|167.32|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|356||||356|47.06|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|356||||356|178|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|356||||356|224.28|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|CIGNA [1260]|CIGNA GWH [126023]|356||||356|195.8|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|356||||356|245.64|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|356||||356|48.21|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|356||||356|52.75|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|356||||356|52.75|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|356||||356|245.64|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|Self-pay|Self-pay|356||||356|124.6|245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|356||||356||245.64|47.06
30180230|EAP|0301 - LABORATORY-CHEMISTRY|HC  DRUG ASSAY INFLIXIMAB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|356||||356||245.64|47.06
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AARP [1000]|AARP [100000]|410||||410|19.13|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|410||||410|18.83|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AETNA [1015]|AETNA [101529]|410||||410|25.49|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|410||||410|15.66|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|410||||410|18.64|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|410||||410|18.64|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BCBS UTHCT [115568]|410||||410|192.7|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|410||||410|22.74|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|410||||410|205|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|410||||410|258.3|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|410||||410|15.66|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|410||||410|18.64|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|CIGNA [1260]|CIGNA GWH [126023]|410||||410|15.86|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|410||||410|282.9|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|410||||410|23.3|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|410||||410|18.64|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|410||||410|25.49|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|410||||410|15.66|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|410||||410|18.64|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|410||||410|25.49|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|410||||410|15.66|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|410||||410|15.66|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|410||||410|282.9|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|410||||410|15.66|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|Self-pay|Self-pay|410||||410|143.5|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|410||||410|15.66|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|410||||410|15.66|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|410||||410|19.13|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|410||||410|18.64|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|410||||410|18.64|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|410||||410|19.13|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|410||||410|18.64|282.9|15.66
30180299|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED QUANTITATIVE ASSAY DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|410||||410|37.28|282.9|15.66
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|AARP [1000]|AARP [100000]|102||||102|79.81|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102||||102|62.76|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|AETNA [1015]|AETNA [101529]|102||||102|85.01|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102||||102|52.2|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102||||102|62.14|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102||||102|62.14|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|BCBS [1155]|BCBS UTHCT [115568]|102||||102|47.94|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102||||102|87.63|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102||||102|51|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102||||102|64.26|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102||||102|52.2|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102||||102|62.14|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|CIGNA [1260]|CIGNA GWH [126023]|102||||102|56.1|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|102||||102|70.38|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102||||102|77.68|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102||||102|62.14|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102||||102|85.01|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102||||102|52.2|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102||||102|62.14|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102||||102|85.01|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102||||102|52.2|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|102||||102|52.2|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|102||||102|70.38|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102||||102|52.2|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|Self-pay|Self-pay|102||||102|35.7|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102||||102|52.2|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102||||102|52.2|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102||||102|79.81|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102||||102|62.14|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102||||102|62.14|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102||||102|79.81|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102||||102|62.14|124.28|35.7
30180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG TEST PRESUMP INSTR CHEM ANALYZ PER DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102||||102|124.28|124.28|35.7
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|AARP [1000]|AARP [100000]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|AETNA [1015]|AETNA [101529]|91||||91|44.62|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|BCBS [1155]|BCBS UTHCT [115568]|91||||91|42.77|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|91||||91|49.13|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|91||||91|45.5|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|91||||91|57.33|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|CIGNA [1260]|CIGNA GWH [126023]|91||||91|55.24|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|91||||91|62.79|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|91||||91|40.78|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|91||||91|44.62|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|91||||91|44.62|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|91||||91|62.79|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|Self-pay|Self-pay|91||||91|31.85|62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|91||||91||62.79|31.85
30180400|EAP|0301 - LABORATORY-CHEMISTRY|HC ACTH STIM PANEL ADRENAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|91||||91||62.79|31.85
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|AARP [1000]|AARP [100000]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|AETNA [1015]|AETNA [101529]|60||||60|5.5|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|BCBS [1155]|BCBS UTHCT [115568]|60||||60|28.2|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60||||60|4.9|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60||||60|30|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60||||60|37.8|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|CIGNA [1260]|CIGNA GWH [126023]|60||||60|5.89|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|60||||60|41.4|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|60||||60|5.03|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60||||60|5.5|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60||||60|5.5|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|60||||60|41.4|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|Self-pay|Self-pay|60||||60|21|41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60||||60||41.4|4.9
30181000|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS NONAUTO W/ MICRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60||||60||41.4|4.9
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|AARP [1000]|AARP [100000]|681||||681|197.59|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|681||||681|146.29|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|AETNA [1015]|AETNA [101529]|681||||681|198.14|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|681||||681|121.67|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|681||||681|144.84|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|681||||681|144.84|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|BCBS [1155]|BCBS UTHCT [115568]|681||||681|320.07|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|681||||681|218.15|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|681||||681|340.5|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|681||||681|429.03|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|681||||681|121.67|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|681||||681|144.84|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|CIGNA [1260]|CIGNA GWH [126023]|681||||681|374.55|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|681||||681|469.89|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|681||||681|181.05|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|681||||681|144.84|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|681||||681|198.14|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|681||||681|121.67|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|681||||681|144.84|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|681||||681|198.14|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|681||||681|121.67|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|681||||681|121.67|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|681||||681|469.89|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|681||||681|121.67|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|Self-pay|Self-pay|681||||681|238.35|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|681||||681|121.67|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|681||||681|121.67|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|681||||681|197.59|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|681||||681|144.84|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|681||||681|144.84|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|681||||681|197.59|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|681||||681|144.84|469.89|121.67
30181207|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR-ABL1-MINOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|681||||681|289.68|469.89|121.67
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|AARP [1000]|AARP [100000]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|AETNA [1015]|AETNA [101529]|935||||935|761.42|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|BCBS [1155]|BCBS UTHCT [115568]|935||||935|439.45|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|935||||935|679.05|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|935||||935|467.5|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|935||||935|589.05|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|CIGNA [1260]|CIGNA GWH [126023]|935||||935|514.25|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|935||||935|645.15|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|935||||935|695.75|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|935||||935|761.42|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|935||||935|761.42|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|935||||935|645.15|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|Self-pay|Self-pay|935||||935|327.25|761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|935||||935||761.42|327.25
30181220|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE COM VARIANTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|935||||935||761.42|327.25
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|AARP [1000]|AARP [100000]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|AETNA [1015]|AETNA [101529]|315||||315|78.02|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|BCBS [1155]|BCBS UTHCT [115568]|315||||315|148.05|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|315||||315|69.59|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|315||||315|157.5|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|315||||315|198.45|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|CIGNA [1260]|CIGNA GWH [126023]|315||||315|173.25|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|315||||315|217.35|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|315||||315|71.3|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|315||||315|78.02|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|315||||315|78.02|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|315||||315|217.35|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|Self-pay|Self-pay|315||||315|110.25|217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|315||||315||217.35|69.59
30181243|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE DETECTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|315||||315||217.35|69.59
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|AARP [1000]|AARP [100000]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|AETNA [1015]|AETNA [101529]|1425||||1425|61.42|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|BCBS [1155]|BCBS UTHCT [115568]|1425||||1425|669.75|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1425||||1425|54.77|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1425||||1425|712.5|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1425||||1425|897.75|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|CIGNA [1260]|CIGNA GWH [126023]|1425||||1425|783.75|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1425||||1425|983.25|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1425||||1425|56.11|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1425||||1425|61.42|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1425||||1425|61.42|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1425||||1425|983.25|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|Self-pay|Self-pay|1425||||1425|498.75|983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1425||||1425||983.25|54.77
30181244|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC FMR1 GENE ANALYSIS CHARACTERIZATION OF ALLELES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1425||||1425||983.25|54.77
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AARP [1000]|AARP [100000]|192||||192|59.55|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|192||||192|65.99|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AETNA [1015]|AETNA [101529]|192||||192|89.38|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|192||||192|54.89|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|192||||192|65.34|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|192||||192|65.34|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BCBS UTHCT [115568]|192||||192|90.24|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|192||||192|79.71|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|192||||192|96|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|192||||192|120.96|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|192||||192|54.89|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|192||||192|65.34|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|CIGNA [1260]|CIGNA GWH [126023]|192||||192|105.6|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|192||||192|132.48|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|192||||192|81.68|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|192||||192|65.34|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|192||||192|89.38|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|192||||192|54.89|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|192||||192|65.34|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|192||||192|89.38|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|192||||192|54.89|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|192||||192|54.89|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|192||||192|132.48|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|192||||192|54.89|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|Self-pay|Self-pay|192||||192|67.2|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|192||||192|54.89|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|192||||192|54.89|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|192||||192|59.55|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|192||||192|65.34|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|192||||192|65.34|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|192||||192|59.55|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|192||||192|65.34|132.48|54.89
30181291|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MTHFR GENE ANALYSIS COMMON VARIANTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|192||||192|130.68|132.48|54.89
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|AARP [1000]|AARP [100000]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|AETNA [1015]|AETNA [101529]|1008||||1008|285.79|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|BCBS [1155]|BCBS UTHCT [115568]|1008||||1008|473.76|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1008||||1008|314.66|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1008||||1008|504|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1008||||1008|635.04|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|CIGNA [1260]|CIGNA GWH [126023]|1008||||1008|554.4|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1008||||1008|695.52|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1008||||1008|261.15|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1008||||1008|285.79|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1008||||1008|285.79|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1008||||1008|695.52|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|Self-pay|Self-pay|1008||||1008|352.8|695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1008||||1008||695.52|261.15
30181340|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRB@ REARRANGEMENT ANAL AMPLIFICATION METHOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1008||||1008||695.52|261.15
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|AARP [1000]|AARP [100000]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|AETNA [1015]|AETNA [101529]|3764||||3764|817.94|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3764||||3764|1116.03|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|BCBS [1155]|BCBS UTHCT [115568]|3764||||3764|1769.08|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3764||||3764|734.56|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3764||||3764|1882|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3764||||3764|2371.32|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3764||||3764|1116.03|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|CIGNA [1260]|CIGNA GWH [126023]|3764||||3764|2070.2|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3764||||3764|2597.16|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3764||||3764|747.39|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3764||||3764|817.94|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3764||||3764|1116.03|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3764||||3764|817.94|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3764||||3764|1116.03|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3764||||3764|1116.03|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3764||||3764|2597.16|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3764||||3764|1116.03|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|Self-pay|Self-pay|3764||||3764|1317.4|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3764||||3764|1116.03|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3764||||3764|1116.03|2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3764||||3764||2597.16|734.56
30181445|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOLID ORGAN NEOPLASM 5-50 GENE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3764||||3764||2597.16|734.56
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|AARP [1000]|AARP [100000]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|AETNA [1015]|AETNA [101529]|5200||||5200|1039.03|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|BCBS [1155]|BCBS UTHCT [115568]|5200||||5200|2444|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5200||||5200|796.59|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5200||||5200|2600|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5200||||5200|3276|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|CIGNA [1260]|CIGNA GWH [126023]|5200||||5200|2860|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5200||||5200|3588|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5200||||5200|949.41|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5200||||5200|1039.03|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5200||||5200|1039.03|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5200||||5200|3588|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|Self-pay|Self-pay|5200||||5200|1820|3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5200||||5200||3588|796.59
30181450|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS HEMATOLYMPHOID NEO 5-50 GENE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5200||||5200||3588|796.59
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|AARP [1000]|AARP [100000]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|AETNA [1015]|AETNA [101529]|58||||58|6.19|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|BCBS [1155]|BCBS UTHCT [115568]|58||||58|27.26|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58||||58|6.81|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58||||58|29|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58||||58|36.54|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|CIGNA [1260]|CIGNA GWH [126023]|58||||58|5.39|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|58||||58|40.02|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58||||58|5.65|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58||||58|6.19|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58||||58|6.19|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|58||||58|40.02|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|Self-pay|Self-pay|58||||58|20.3|40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58||||58||40.02|5.39
30182009|EAP|0301 - LABORATORY-CHEMISTRY|HC ACETONE/KETONES SERUM QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58||||58||40.02|5.39
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AARP [1000]|AARP [100000]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AETNA [1015]|AETNA [101529]|23||||23|11.18|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BCBS UTHCT [115568]|23||||23|10.81|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23||||23|12.31|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23||||23|11.5|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23||||23|14.49|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|CIGNA [1260]|CIGNA GWH [126023]|23||||23|15.41|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23||||23|15.87|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23||||23|10.21|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23||||23|11.18|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23||||23|11.18|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23||||23|15.87|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|Self-pay|Self-pay|23||||23|8.05|15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23||||23||15.87|8.05
30182010|EAP|0301 - LABORATORY-CHEMISTRY|HC KETONE BODY(S) QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23||||23||15.87|8.05
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|AARP [1000]|AARP [100000]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|AETNA [1015]|AETNA [101529]|54||||54|22.56|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|BCBS [1155]|BCBS UTHCT [115568]|54||||54|25.38|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54||||54|20.9|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54||||54|27|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54||||54|34.02|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|CIGNA [1260]|CIGNA GWH [126023]|54||||54|16.14|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54||||54|37.26|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54||||54|20.61|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54||||54|22.56|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54||||54|22.56|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54||||54|37.26|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|Self-pay|Self-pay|54||||54|18.9|37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54||||54||37.26|16.14
30182016|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QUALITATIVE EACH SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54||||54||37.26|16.14
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|AARP [1000]|AARP [100000]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|AETNA [1015]|AETNA [101529]|154||||154|23.09|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|BCBS [1155]|BCBS UTHCT [115568]|154||||154|72.38|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|154||||154|25.41|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|154||||154|77|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|154||||154|97.02|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|CIGNA [1260]|CIGNA GWH [126023]|154||||154|19.54|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|154||||154|106.26|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|154||||154|21.09|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|154||||154|23.09|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|154||||154|23.09|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|154||||154|106.26|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|Self-pay|Self-pay|154||||154|53.9|106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|154||||154||106.26|19.54
30182017|EAP|0301 - LABORATORY-CHEMISTRY|HC ACYLCARNITINES QN EA SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|154||||154||106.26|19.54
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AARP [1000]|AARP [100000]|438||||438|53.97|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|438||||438|39.01|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AETNA [1015]|AETNA [101529]|438||||438|52.82|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|438||||438|32.44|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|438||||438|38.62|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|438||||438|38.62|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BCBS UTHCT [115568]|438||||438|205.86|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|438||||438|58.17|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|438||||438|219|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|438||||438|275.94|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|438||||438|32.44|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|438||||438|38.62|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|CIGNA [1260]|CIGNA GWH [126023]|438||||438|44.76|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|438||||438|302.22|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|438||||438|48.28|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|438||||438|38.62|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|438||||438|52.82|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|438||||438|32.44|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|438||||438|38.62|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|438||||438|52.82|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|438||||438|32.44|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|438||||438|32.44|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|438||||438|302.22|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|438||||438|32.44|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|Self-pay|Self-pay|438||||438|153.3|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|438||||438|32.44|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|438||||438|32.44|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|438||||438|53.97|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|438||||438|38.62|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|438||||438|38.62|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|438||||438|53.97|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|438||||438|38.62|302.22|32.44
30182024|EAP|0301 - LABORATORY-CHEMISTRY|HC ADRENOCORTICOTROPIC (ACTH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|438||||438|77.24|302.22|32.44
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AARP [1000]|AARP [100000]|64||||64|6.92|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64||||64|5|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AETNA [1015]|AETNA [101529]|64||||64|6.77|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64||||64|4.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64||||64|4.95|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64||||64|4.95|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BCBS UTHCT [115568]|64||||64|30.08|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64||||64|7.45|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64||||64|32|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64||||64|40.32|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64||||64|4.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64||||64|4.95|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|CIGNA [1260]|CIGNA GWH [126023]|64||||64|5.66|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|64||||64|44.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|64||||64|6.19|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64||||64|4.95|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64||||64|6.77|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64||||64|4.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64||||64|4.95|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64||||64|6.77|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64||||64|4.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|64||||64|4.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|64||||64|44.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64||||64|4.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|Self-pay|Self-pay|64||||64|22.4|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|64||||64|4.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64||||64|4.16|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64||||64|6.92|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|64||||64|4.95|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|64||||64|4.95|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64||||64|6.92|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64||||64|4.95|44.16|4.16
30182040|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN SERUM QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64||||64|9.9|44.16|4.16
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AARP [1000]|AARP [100000]|128||||128|7.23|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128||||128|7.86|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AETNA [1015]|AETNA [101529]|128||||128|10.63|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128||||128|6.54|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128||||128|7.78|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128||||128|7.78|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BCBS UTHCT [115568]|128||||128|60.16|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128||||128|9.49|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128||||128|64|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128||||128|80.64|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128||||128|6.54|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128||||128|7.78|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|CIGNA [1260]|CIGNA GWH [126023]|128||||128|5.95|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|128||||128|88.32|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|128||||128|9.73|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128||||128|7.78|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128||||128|10.63|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128||||128|6.54|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128||||128|7.78|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128||||128|10.63|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128||||128|6.54|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|128||||128|6.54|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|128||||128|88.32|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128||||128|6.54|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|Self-pay|Self-pay|128||||128|44.8|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|128||||128|6.54|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128||||128|6.54|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128||||128|7.23|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|128||||128|7.78|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|128||||128|7.78|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128||||128|7.23|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128||||128|7.78|88.32|5.95
30182042|EAP|0301 - LABORATORY-CHEMISTRY|HC ALBUMIN OTHER SOURCE QN EA SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128||||128|15.56|88.32|5.95
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|AARP [1000]|AARP [100000]|175||||175|8.09|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175||||175|5.84|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|AETNA [1015]|AETNA [101529]|175||||175|7.9|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175||||175|4.86|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175||||175|5.78|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175||||175|5.78|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|BCBS [1155]|BCBS UTHCT [115568]|175||||175|82.25|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175||||175|8.71|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175||||175|87.5|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175||||175|110.25|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175||||175|4.86|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175||||175|5.78|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|CIGNA [1260]|CIGNA GWH [126023]|175||||175|6.79|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|175||||175|120.75|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|175||||175|7.23|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175||||175|5.78|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175||||175|7.9|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175||||175|4.86|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175||||175|5.78|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175||||175|7.9|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175||||175|4.86|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|175||||175|4.86|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|175||||175|120.75|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175||||175|4.86|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|Self-pay|Self-pay|175||||175|61.25|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|175||||175|4.86|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175||||175|4.86|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175||||175|8.09|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|175||||175|5.78|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|175||||175|5.78|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175||||175|8.09|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175||||175|5.78|120.75|4.86
30182043|EAP|0301 - LABORATORY-CHEMISTRY|HC MICROALBUMIN URINE QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175||||175|11.56|120.75|4.86
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|AARP [1000]|AARP [100000]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|AETNA [1015]|AETNA [101529]|32||||32|0.02|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|BCBS [1155]|BCBS UTHCT [115568]|32||||32|15.04|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32||||32|32|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32||||32|16|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32||||32|20.16|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|CIGNA [1260]|CIGNA GWH [126023]|32||||32|13.88|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|32||||32|22.08|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|32||||32|37.5|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32||||32|0.02|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32||||32|0.02|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|32||||32|22.08|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|Self-pay|Self-pay|32||||32|11.2|37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32||||32||37.5|0.02
30182075|EAP|0301 - LABORATORY-CHEMISTRY|HC ASSAY OF BREATH ETHANOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32||||32||37.5|0.02
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AARP [1000]|AARP [100000]|183||||183|13.56|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|183||||183|9.81|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AETNA [1015]|AETNA [101529]|183||||183|13.27|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|183||||183|8.16|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|183||||183|9.71|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|183||||183|9.71|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BCBS UTHCT [115568]|183||||183|86.01|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|183||||183|14.63|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|183||||183|91.5|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|183||||183|115.29|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|183||||183|8.16|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|183||||183|9.71|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|CIGNA [1260]|CIGNA GWH [126023]|183||||183|11.33|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|183||||183|126.27|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|183||||183|12.14|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|183||||183|9.71|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|183||||183|13.27|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|183||||183|8.16|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|183||||183|9.71|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|183||||183|13.27|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|183||||183|8.16|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|183||||183|8.16|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|183||||183|126.27|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|183||||183|8.16|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|Self-pay|Self-pay|183||||183|64.05|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|183||||183|8.16|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|183||||183|8.16|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|183||||183|13.56|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|183||||183|9.71|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|183||||183|9.71|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|183||||183|13.56|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|183||||183|9.71|126.27|8.16
30182085|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOLASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|183||||183|19.42|126.27|8.16
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AARP [1000]|AARP [100000]|519||||519|56.94|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|519||||519|41.16|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AETNA [1015]|AETNA [101529]|519||||519|55.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|519||||519|34.23|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|519||||519|40.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|519||||519|40.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BCBS UTHCT [115568]|519||||519|243.93|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|519||||519|61.38|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|519||||519|259.5|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|519||||519|326.97|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|519||||519|34.23|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|519||||519|40.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|CIGNA [1260]|CIGNA GWH [126023]|519||||519|47.3|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|519||||519|358.11|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|519||||519|50.94|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|519||||519|40.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|519||||519|55.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|519||||519|34.23|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|519||||519|40.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|519||||519|55.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|519||||519|34.23|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|519||||519|34.23|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|519||||519|358.11|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|519||||519|34.23|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|Self-pay|Self-pay|519||||519|181.65|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|519||||519|34.23|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|519||||519|34.23|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|519||||519|56.94|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|519||||519|40.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|519||||519|40.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|519||||519|56.94|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|519||||519|40.75|358.11|34.23
30182088|EAP|0301 - LABORATORY-CHEMISTRY|HC ALDOSTERONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|519||||519|81.5|358.11|34.23
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|AARP [1000]|AARP [100000]|287||||287|18.77|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|287||||287|13.57|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|AETNA [1015]|AETNA [101529]|287||||287|18.38|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|287||||287|11.29|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|287||||287|13.44|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|287||||287|13.44|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|287||||287|134.89|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|287||||287|20.24|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|287||||287|143.5|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|287||||287|180.81|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|287||||287|11.29|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|287||||287|13.44|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|287||||287|15.58|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|287||||287|198.03|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|287||||287|16.8|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|287||||287|13.44|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|287||||287|18.38|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|287||||287|11.29|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|287||||287|13.44|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|287||||287|18.38|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|287||||287|11.29|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|287||||287|11.29|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|287||||287|198.03|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|287||||287|11.29|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|Self-pay|Self-pay|287||||287|100.45|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|287||||287|11.29|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|287||||287|11.29|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|287||||287|18.77|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|287||||287|13.44|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|287||||287|13.44|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|287||||287|18.77|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|287||||287|13.44|198.03|11.29
30182103|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|287||||287|26.88|198.03|11.29
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|AARP [1000]|AARP [100000]|117||||117|20.2|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|117||||117|14.6|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|AETNA [1015]|AETNA [101529]|117||||117|19.78|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|117||||117|12.15|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|117||||117|14.46|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|117||||117|14.46|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|BCBS [1155]|BCBS UTHCT [115568]|117||||117|54.99|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|117||||117|21.79|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|117||||117|58.5|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|117||||117|73.71|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|117||||117|12.15|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|117||||117|14.46|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|CIGNA [1260]|CIGNA GWH [126023]|117||||117|16.72|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|117||||117|80.73|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|117||||117|18.08|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|117||||117|14.46|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|117||||117|19.78|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|117||||117|12.15|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|117||||117|14.46|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|117||||117|19.78|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|117||||117|12.15|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|117||||117|12.15|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|117||||117|80.73|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|117||||117|12.15|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|Self-pay|Self-pay|117||||117|40.95|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|117||||117|12.15|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|117||||117|12.15|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|117||||117|20.2|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|117||||117|14.46|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|117||||117|14.46|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|117||||117|20.2|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|117||||117|14.46|80.73|12.15
30182104|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA-1-ANTITRYPSIN PHENOTYPE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|117||||117|28.92|80.73|12.15
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AARP [1000]|AARP [100000]|245||||245|23.44|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|245||||245|16.94|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AETNA [1015]|AETNA [101529]|245||||245|22.94|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|245||||245|14.09|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|245||||245|16.77|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|245||||245|16.77|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BCBS UTHCT [115568]|245||||245|115.15|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|245||||245|25.27|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|245||||245|122.5|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|245||||245|154.35|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|245||||245|14.09|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|245||||245|16.77|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|CIGNA [1260]|CIGNA GWH [126023]|245||||245|19.54|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|245||||245|169.05|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|245||||245|20.96|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|245||||245|16.77|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|245||||245|22.94|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|245||||245|14.09|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|245||||245|16.77|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|245||||245|22.94|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|245||||245|14.09|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|245||||245|14.09|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|245||||245|169.05|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|245||||245|14.09|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|Self-pay|Self-pay|245||||245|85.75|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|245||||245|14.09|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|245||||245|14.09|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|245||||245|23.44|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|245||||245|16.77|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|245||||245|16.77|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|245||||245|23.44|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|245||||245|16.77|169.05|14.09
30182105|EAP|0301 - LABORATORY-CHEMISTRY|HC ALPHA FETOPROTEIN SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|245||||245|33.54|169.05|14.09
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|AARP [1000]|AARP [100000]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|AETNA [1015]|AETNA [101529]|55||||55|18.98|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|BCBS [1155]|BCBS UTHCT [115568]|55||||55|25.85|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|55||||55|20.9|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|55||||55|27.5|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|55||||55|34.65|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|CIGNA [1260]|CIGNA GWH [126023]|55||||55|16.14|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|55||||55|37.95|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|55||||55|17.34|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55||||55|18.98|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55||||55|18.98|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|55||||55|37.95|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|Self-pay|Self-pay|55||||55|19.25|37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|55||||55||37.95|16.14
30182128|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QL SERUM MULTIPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|55||||55||37.95|16.14
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AARP [1000]|AARP [100000]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AETNA [1015]|AETNA [101529]|77||||77|31.44|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS [1155]|BCBS UTHCT [115568]|77||||77|36.19|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|77||||77|28.04|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|77||||77|38.5|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|77||||77|48.51|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|CIGNA [1260]|CIGNA GWH [126023]|77||||77|19.54|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|77||||77|53.13|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|77||||77|28.73|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|77||||77|31.44|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|77||||77|31.44|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|77||||77|53.13|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|Self-pay|Self-pay|77||||77|26.95|53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|77||||77||53.13|19.54
30182131|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS QN SINGLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|77||||77||53.13|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|AARP [1000]|AARP [100000]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|AETNA [1015]|AETNA [101529]|116||||116|23.09|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|25.41|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|19.54|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|21.09|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|23.09|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|23.09|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|Self-pay|Self-pay|116||||116|40.6|80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116||80.04|19.54
30182139|EAP|0301 - LABORATORY-CHEMISTRY|HC AMINO ACIDS 6+ QN EACH SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116||80.04|19.54
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AARP [1000]|AARP [100000]|173||||173|20.36|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|173||||173|14.72|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AETNA [1015]|AETNA [101529]|173||||173|19.92|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|173||||173|12.24|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|173||||173|14.57|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|173||||173|14.57|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BCBS UTHCT [115568]|173||||173|81.31|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|173||||173|21.95|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|173||||173|86.5|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|173||||173|108.99|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|173||||173|12.24|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|173||||173|14.57|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|CIGNA [1260]|CIGNA GWH [126023]|173||||173|16.99|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|173||||173|119.37|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|173||||173|18.21|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|173||||173|14.57|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|173||||173|19.92|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|173||||173|12.24|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|173||||173|14.57|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|173||||173|19.92|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|173||||173|12.24|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|173||||173|12.24|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|173||||173|119.37|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|173||||173|12.24|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|Self-pay|Self-pay|173||||173|60.55|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|173||||173|12.24|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|173||||173|12.24|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|173||||173|20.36|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|173||||173|14.57|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|173||||173|14.57|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|173||||173|20.36|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|173||||173|14.57|119.37|12.24
30182140|EAP|0301 - LABORATORY-CHEMISTRY|HC AMMONIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|173||||173|29.14|119.37|12.24
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AARP [1000]|AARP [100000]|175||||175|9.06|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175||||175|6.54|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AETNA [1015]|AETNA [101529]|175||||175|8.86|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175||||175|5.44|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175||||175|6.48|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175||||175|6.48|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BCBS UTHCT [115568]|175||||175|82.25|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175||||175|9.76|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175||||175|87.5|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175||||175|110.25|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175||||175|5.44|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175||||175|6.48|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|CIGNA [1260]|CIGNA GWH [126023]|175||||175|7.64|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|175||||175|120.75|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|175||||175|8.1|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175||||175|6.48|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175||||175|8.86|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175||||175|5.44|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175||||175|6.48|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175||||175|8.86|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175||||175|5.44|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|175||||175|5.44|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|175||||175|120.75|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175||||175|5.44|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|Self-pay|Self-pay|175||||175|61.25|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|175||||175|5.44|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175||||175|5.44|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175||||175|9.06|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|175||||175|6.48|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|175||||175|6.48|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175||||175|9.06|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175||||175|6.48|120.75|5.44
30182150|EAP|0301 - LABORATORY-CHEMISTRY|HC AMYLASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175||||175|12.96|120.75|5.44
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|AARP [1000]|AARP [100000]|123||||123|40.9|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|123||||123|29.57|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|AETNA [1015]|AETNA [101529]|123||||123|40.06|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|123||||123|24.6|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|123||||123|29.28|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|123||||123|29.28|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|BCBS [1155]|BCBS UTHCT [115568]|123||||123|57.81|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|123||||123|44.09|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|123||||123|61.5|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|123||||123|77.49|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|123||||123|24.6|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|123||||123|29.28|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|CIGNA [1260]|CIGNA GWH [126023]|123||||123|34|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|123||||123|84.87|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|123||||123|36.6|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|123||||123|29.28|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|123||||123|40.06|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|123||||123|24.6|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|123||||123|29.28|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|123||||123|40.06|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|123||||123|24.6|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|123||||123|24.6|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|123||||123|84.87|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|123||||123|24.6|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|Self-pay|Self-pay|123||||123|43.05|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|123||||123|24.6|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|123||||123|24.6|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|123||||123|40.9|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|123||||123|29.28|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|123||||123|29.28|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|123||||123|40.9|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|123||||123|29.28|84.87|24.6
30182157|EAP|0301 - LABORATORY-CHEMISTRY|HC ANDROSTENEDIONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|123||||123|58.56|84.87|24.6
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AARP [1000]|AARP [100000]|253||||253|20.39|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|253||||253|14.75|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AETNA [1015]|AETNA [101529]|253||||253|19.97|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|253||||253|12.26|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|253||||253|14.6|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|253||||253|14.6|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BCBS UTHCT [115568]|253||||253|118.91|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|253||||253|22|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|253||||253|126.5|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|253||||253|159.39|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|253||||253|12.26|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|253||||253|14.6|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|CIGNA [1260]|CIGNA GWH [126023]|253||||253|16.99|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|253||||253|174.57|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|253||||253|18.25|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|253||||253|14.6|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|253||||253|19.97|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|253||||253|12.26|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|253||||253|14.6|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|253||||253|19.97|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|253||||253|12.26|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|253||||253|12.26|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|253||||253|174.57|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|253||||253|12.26|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|Self-pay|Self-pay|253||||253|88.55|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|253||||253|12.26|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|253||||253|12.26|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|253||||253|20.39|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|253||||253|14.6|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|253||||253|14.6|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|253||||253|20.39|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|253||||253|14.6|174.57|12.26
30182164|EAP|0301 - LABORATORY-CHEMISTRY|HC ANGIOTENSIN I ENZYME (ACE)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|253||||253|29.2|174.57|12.26
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|AARP [1000]|AARP [100000]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|AETNA [1015]|AETNA [101529]|117||||117|28.85|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|BCBS [1155]|BCBS UTHCT [115568]|117||||117|54.99|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|117||||117|25.73|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|117||||117|58.5|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|117||||117|73.71|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|CIGNA [1260]|CIGNA GWH [126023]|117||||117|18.13|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|117||||117|80.73|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|117||||117|26.36|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|117||||117|28.85|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|117||||117|28.85|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|117||||117|80.73|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|Self-pay|Self-pay|117||||117|40.95|80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|117||||117||80.73|18.13
30182172|EAP|0301 - LABORATORY-CHEMISTRY|HC APOLIPOPROTEIN EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|117||||117||80.73|18.13
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|AARP [1000]|AARP [100000]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|AETNA [1015]|AETNA [101529]|441||||441|25.94|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|BCBS [1155]|BCBS UTHCT [115568]|441||||441|207.27|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|441||||441|28.57|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|441||||441|220.5|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|441||||441|277.83|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|CIGNA [1260]|CIGNA GWH [126023]|441||||441|22.09|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|441||||441|304.29|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|441||||441|23.71|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|441||||441|25.94|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|441||||441|25.94|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|441||||441|304.29|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|Self-pay|Self-pay|441||||441|154.35|304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|441||||441||304.29|22.09
30182175|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN ARSENIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|441||||441||304.29|22.09
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|AARP [1000]|AARP [100000]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|AETNA [1015]|AETNA [101529]|20||||20|13.54|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|BCBS [1155]|BCBS UTHCT [115568]|20||||20|9.4|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|14.88|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|10|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|12.6|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|CIGNA [1260]|CIGNA GWH [126023]|20||||20|11.62|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20||||20|12.36|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|13.54|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|13.54|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|Self-pay|Self-pay|20||||20|7|14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20||14.88|7
30182180|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN C (ASCORBIC ACID)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20||||20||14.88|7
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AARP [1000]|AARP [100000]|215||||215|22.61|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|215||||215|16.34|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AETNA [1015]|AETNA [101529]|215||||215|22.13|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|215||||215|13.59|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|215||||215|16.18|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|215||||215|16.18|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS [1155]|BCBS UTHCT [115568]|215||||215|101.05|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|215||||215|24.36|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|215||||215|107.5|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|215||||215|135.45|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|215||||215|13.59|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|215||||215|16.18|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|CIGNA [1260]|CIGNA GWH [126023]|215||||215|18.7|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|215||||215|148.35|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|215||||215|20.23|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|215||||215|16.18|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|215||||215|22.13|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|215||||215|13.59|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|215||||215|16.18|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|215||||215|22.13|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|215||||215|13.59|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|215||||215|13.59|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|215||||215|148.35|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|215||||215|13.59|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|Self-pay|Self-pay|215||||215|75.25|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|215||||215|13.59|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|215||||215|13.59|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|215||||215|22.61|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|215||||215|16.18|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|215||||215|16.18|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|215||||215|22.61|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|215||||215|16.18|148.35|13.59
30182232|EAP|0301 - LABORATORY-CHEMISTRY|HC BETA-2 MICROGLOBULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|215||||215|32.36|148.35|13.59
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AARP [1000]|AARP [100000]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AETNA [1015]|AETNA [101529]|89||||89|6.86|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|89||||89|41.83|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89||||89|7.55|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89||||89|44.5|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89||||89|56.07|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|89||||89|9.52|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|89||||89|61.41|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|89||||89|6.28|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89||||89|6.86|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89||||89|6.86|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|89||||89|61.41|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|Self-pay|Self-pay|89||||89|31.15|61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89||||89||61.41|6.28
30182247|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|89||||89||61.41|6.28
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AARP [1000]|AARP [100000]|135||||135|7.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135||||135|5.07|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AETNA [1015]|AETNA [101529]|135||||135|6.86|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135||||135|4.22|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135||||135|5.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135||||135|5.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BCBS UTHCT [115568]|135||||135|63.45|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135||||135|7.55|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135||||135|67.5|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135||||135|85.05|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135||||135|4.22|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135||||135|5.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|CIGNA [1260]|CIGNA GWH [126023]|135||||135|9.52|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|135||||135|93.15|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|135||||135|6.28|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135||||135|5.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135||||135|6.86|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135||||135|4.22|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135||||135|5.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135||||135|6.86|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135||||135|4.22|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|135||||135|4.22|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|135||||135|93.15|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135||||135|4.22|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|Self-pay|Self-pay|135||||135|47.25|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|135||||135|4.22|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135||||135|4.22|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135||||135|7.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|135||||135|5.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|135||||135|5.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135||||135|7.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135||||135|5.02|93.15|4.22
30182248|EAP|0301 - LABORATORY-CHEMISTRY|HC BILIRUBIN DIRECT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135||||135|10.04|93.15|4.22
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|AARP [1000]|AARP [100000]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|AETNA [1015]|AETNA [101529]|150||||150|23.09|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|BCBS [1155]|BCBS UTHCT [115568]|150||||150|70.5|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|150||||150|25.41|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|150||||150|75|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|150||||150|94.5|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|CIGNA [1260]|CIGNA GWH [126023]|150||||150|19.54|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|150||||150|103.5|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|150||||150|21.09|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|150||||150|23.09|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|150||||150|23.09|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|150||||150|103.5|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|Self-pay|Self-pay|150||||150|52.5|103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|150||||150||103.5|19.54
30182261|EAP|0301 - LABORATORY-CHEMISTRY|HC BIOTINIDASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|150||||150||103.5|19.54
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AARP [1000]|AARP [100000]|81||||81|4.54|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81||||81|4.42|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AETNA [1015]|AETNA [101529]|81||||81|6|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81||||81|3.68|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81||||81|4.38|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|81||||81|4.38|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BCBS UTHCT [115568]|81||||81|38.07|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81||||81|5.34|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81||||81|40.5|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81||||81|51.03|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81||||81|3.68|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81||||81|4.38|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|CIGNA [1260]|CIGNA GWH [126023]|81||||81|5.89|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|81||||81|55.89|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|81||||81|5.48|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|81||||81|4.38|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81||||81|6|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81||||81|3.68|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81||||81|4.38|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81||||81|6|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|81||||81|3.68|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|81||||81|3.68|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|81||||81|55.89|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81||||81|3.68|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|Self-pay|Self-pay|81||||81|28.35|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|81||||81|3.68|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81||||81|3.68|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81||||81|4.54|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|81||||81|4.38|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|81||||81|4.38|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81||||81|4.54|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81||||81|4.38|55.89|3.68
30182270|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD STOOL GUAIAC 1-3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|81||||81|8.76|55.89|3.68
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|AARP [1000]|AARP [100000]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|63||||63|7.27|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|BCBS [1155]|BCBS UTHCT [115568]|63||||63|29.61|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63||||63|6.49|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63||||63|31.5|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63||||63|39.69|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|CIGNA [1260]|CIGNA GWH [126023]|63||||63|5.89|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63||||63|43.47|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63||||63|6.65|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63||||63|7.27|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63||||63|7.27|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63||||63|43.47|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|Self-pay|Self-pay|63||||63|22.05|43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63||||63||43.47|5.89
30182271|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLOOD OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63||||63||43.47|5.89
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|AARP [1000]|AARP [100000]|72||||72|4.54|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72||||72|4.27|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|AETNA [1015]|AETNA [101529]|72||||72|5.78|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72||||72|3.55|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72||||72|4.23|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72||||72|4.23|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|BCBS [1155]|BCBS UTHCT [115568]|72||||72|33.84|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72||||72|5.16|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72||||72|36|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72||||72|45.36|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72||||72|3.55|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72||||72|4.23|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|CIGNA [1260]|CIGNA GWH [126023]|72||||72|5.89|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|72||||72|49.68|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|72||||72|5.29|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72||||72|4.23|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72||||72|5.78|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72||||72|3.55|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72||||72|4.23|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72||||72|5.78|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72||||72|3.55|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|72||||72|3.55|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|72||||72|49.68|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72||||72|3.55|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|Self-pay|Self-pay|72||||72|25.2|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|72||||72|3.55|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72||||72|3.55|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72||||72|4.54|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|72||||72|4.23|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|72||||72|4.23|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72||||72|4.54|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72||||72|4.23|49.68|3.55
30182272|EAP|0301 - LABORATORY-CHEMISTRY|HC OCCULT BLD FECES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72||||72|8.46|49.68|3.55
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|AARP [1000]|AARP [100000]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|AETNA [1015]|AETNA [101529]|65||||65|21.77|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|BCBS [1155]|BCBS UTHCT [115568]|65||||65|30.55|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65||||65|23.96|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65||||65|32.5|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65||||65|40.95|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|CIGNA [1260]|CIGNA GWH [126023]|65||||65|29.46|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|65||||65|44.85|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65||||65|19.9|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65||||65|21.77|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65||||65|21.77|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|65||||65|44.85|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|Self-pay|Self-pay|65||||65|22.75|44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65||||65||44.85|19.9
30182274|EAP|0301 - LABORATORY-CHEMISTRY|HC BLOOD OCCULT FECAL HGB DETER IA QL FECES 1-3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65||||65||44.85|19.9
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|AARP [1000]|AARP [100000]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|AETNA [1015]|AETNA [101529]|69||||69|32.33|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|BCBS [1155]|BCBS UTHCT [115568]|69||||69|32.43|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|34.87|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|34.5|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|43.47|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|CIGNA [1260]|CIGNA GWH [126023]|69||||69|26.92|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|69||||69|29.55|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|32.33|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|32.33|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|Self-pay|Self-pay|69||||69|24.15|47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69||47.61|24.15
30182300|EAP|0301 - LABORATORY-CHEMISTRY|HC CADMIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69||||69||47.61|24.15
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AARP [1000]|AARP [100000]|525||||525|41.36|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|525||||525|29.9|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AETNA [1015]|AETNA [101529]|525||||525|40.49|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|525||||525|24.86|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|525||||525|29.6|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|525||||525|29.6|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BCBS UTHCT [115568]|525||||525|246.75|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|525||||525|44.59|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|525||||525|262.5|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|525||||525|330.75|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|525||||525|24.86|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|525||||525|29.6|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|CIGNA [1260]|CIGNA GWH [126023]|525||||525|34.27|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|525||||525|362.25|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|525||||525|37|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|525||||525|29.6|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|525||||525|40.49|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|525||||525|24.86|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|525||||525|29.6|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|525||||525|40.49|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|525||||525|24.86|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|525||||525|24.86|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|525||||525|362.25|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|525||||525|24.86|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|Self-pay|Self-pay|525||||525|183.75|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|525||||525|24.86|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|525||||525|24.86|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|525||||525|41.36|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|525||||525|29.6|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|525||||525|29.6|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|525||||525|41.36|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|525||||525|29.6|362.25|24.86
30182306|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D 25-HYDROXY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|525||||525|59.2|362.25|24.86
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|AARP [1000]|AARP [100000]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|AETNA [1015]|AETNA [101529]|260||||260|36.65|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|BCBS [1155]|BCBS UTHCT [115568]|260||||260|122.2|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|260||||260|40.36|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|260||||260|130|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|260||||260|163.8|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|CIGNA [1260]|CIGNA GWH [126023]|260||||260|31.16|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|260||||260|179.4|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|260||||260|33.49|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|260||||260|36.65|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|260||||260|36.65|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|260||||260|179.4|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|Self-pay|Self-pay|260||||260|91|179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|260||||260||179.4|31.16
30182308|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCITONIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|260||||260||179.4|31.16
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AARP [1000]|AARP [100000]|90||||90|7.2|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90||||90|5.21|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AETNA [1015]|AETNA [101529]|90||||90|7.06|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90||||90|4.33|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90||||90|5.16|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90||||90|5.16|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|90||||90|42.3|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90||||90|7.77|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90||||90|45|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90||||90|56.7|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90||||90|4.33|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90||||90|5.16|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|90||||90|5.95|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|90||||90|62.1|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|90||||90|6.45|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90||||90|5.16|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90||||90|7.06|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90||||90|4.33|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90||||90|5.16|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90||||90|7.06|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90||||90|4.33|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|90||||90|4.33|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|90||||90|62.1|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90||||90|4.33|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|Self-pay|Self-pay|90||||90|31.5|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|90||||90|4.33|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90||||90|4.33|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90||||90|7.2|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|90||||90|5.16|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|90||||90|5.16|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90||||90|7.2|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90||||90|5.16|62.1|4.33
30182310|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90||||90|10.32|62.1|4.33
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AARP [1000]|AARP [100000]|242||||242|19.09|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|242||||242|13.82|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AETNA [1015]|AETNA [101529]|242||||242|18.72|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|242||||242|11.49|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|242||||242|13.68|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|242||||242|13.68|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BCBS UTHCT [115568]|242||||242|113.74|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|242||||242|20.59|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|242||||242|121|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|242||||242|152.46|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|242||||242|11.49|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|242||||242|13.68|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|CIGNA [1260]|CIGNA GWH [126023]|242||||242|15.86|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|242||||242|166.98|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|242||||242|17.1|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|242||||242|13.68|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|242||||242|18.72|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|242||||242|11.49|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|242||||242|13.68|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|242||||242|18.72|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|242||||242|11.49|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|242||||242|11.49|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|242||||242|166.98|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|242||||242|11.49|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|Self-pay|Self-pay|242||||242|84.7|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|242||||242|11.49|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|242||||242|11.49|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|242||||242|19.09|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|242||||242|13.68|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|242||||242|13.68|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|242||||242|19.09|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|242||||242|13.68|166.98|11.49
30182330|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM IONIZED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|242||||242|27.36|166.98|11.49
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|AARP [1000]|AARP [100000]|126||||126|8.43|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126||||126|6.09|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|AETNA [1015]|AETNA [101529]|126||||126|8.26|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126||||126|5.07|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126||||126|6.03|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126||||126|6.03|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|BCBS [1155]|BCBS UTHCT [115568]|126||||126|59.22|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126||||126|9.08|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126||||126|63|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126||||126|79.38|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126||||126|5.07|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126||||126|6.03|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|CIGNA [1260]|CIGNA GWH [126023]|126||||126|7.08|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126||||126|86.94|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|126||||126|7.54|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126||||126|6.03|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126||||126|8.26|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126||||126|5.07|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126||||126|6.03|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126||||126|8.26|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126||||126|5.07|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|126||||126|5.07|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126||||126|86.94|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126||||126|5.07|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|Self-pay|Self-pay|126||||126|44.1|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|126||||126|5.07|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126||||126|5.07|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126||||126|8.43|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|126||||126|6.03|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|126||||126|6.03|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126||||126|8.43|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126||||126|6.03|86.94|5.07
30182340|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCIUM 24 HR URINE QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126||||126|12.06|86.94|5.07
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|AARP [1000]|AARP [100000]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|AETNA [1015]|AETNA [101529]|178||||178|17.64|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|BCBS [1155]|BCBS UTHCT [115568]|178||||178|83.66|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|178||||178|19.42|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|178||||178|89|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|178||||178|112.14|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|CIGNA [1260]|CIGNA GWH [126023]|178||||178|15.02|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|178||||178|122.82|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|178||||178|16.13|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|178||||178|17.64|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|178||||178|17.64|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|178||||178|122.82|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|Self-pay|Self-pay|178||||178|62.3|122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|178||||178||122.82|15.02
30182365|EAP|0301 - LABORATORY-CHEMISTRY|HC CALCULUS ANALYSIS INFRARED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|178||||178||122.82|15.02
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|AARP [1000]|AARP [100000]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|AETNA [1015]|AETNA [101529]|189||||189|24.7|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|27.19|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|20.96|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|22.58|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|24.7|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|24.7|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|Self-pay|Self-pay|189||||189|66.15|130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189||130.41|20.96
30182373|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOHYDRATE DEFICIENT TRANSFERRIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189||130.41|20.96
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|AARP [1000]|AARP [100000]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|AETNA [1015]|AETNA [101529]|90||||90|6.67|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|BCBS [1155]|BCBS UTHCT [115568]|90||||90|42.3|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90||||90|7.36|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90||||90|45|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90||||90|56.7|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|CIGNA [1260]|CIGNA GWH [126023]|90||||90|9.07|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|90||||90|62.1|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|90||||90|6.1|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90||||90|6.67|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90||||90|6.67|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|90||||90|62.1|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|Self-pay|Self-pay|90||||90|31.5|62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90||||90||62.1|6.1
30182374|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBON DIOXIDE (BICARB) BL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90||||90||62.1|6.1
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|AARP [1000]|AARP [100000]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|AETNA [1015]|AETNA [101529]|204||||204|16.85|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|18.56|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|14.45|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|15.4|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|16.85|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|16.85|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|Self-pay|Self-pay|204||||204|71.4|140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204||140.76|14.45
30182375|EAP|0301 - LABORATORY-CHEMISTRY|HC CARBOXYHEMOGLOBIN QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204||140.76|14.45
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AARP [1000]|AARP [100000]|245||||245|26.51|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|245||||245|19.15|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AETNA [1015]|AETNA [101529]|245||||245|25.94|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|245||||245|15.93|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|245||||245|18.96|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|245||||245|18.96|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BCBS UTHCT [115568]|245||||245|115.15|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|245||||245|28.56|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|245||||245|122.5|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|245||||245|154.35|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|245||||245|15.93|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|245||||245|18.96|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|CIGNA [1260]|CIGNA GWH [126023]|245||||245|22.09|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|245||||245|169.05|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|245||||245|23.7|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|245||||245|18.96|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|245||||245|25.94|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|245||||245|15.93|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|245||||245|18.96|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|245||||245|25.94|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|245||||245|15.93|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|245||||245|15.93|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|245||||245|169.05|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|245||||245|15.93|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|Self-pay|Self-pay|245||||245|85.75|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|245||||245|15.93|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|245||||245|15.93|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|245||||245|26.51|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|245||||245|18.96|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|245||||245|18.96|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|245||||245|26.51|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|245||||245|18.96|169.05|15.93
30182378|EAP|0301 - LABORATORY-CHEMISTRY|HC AG CARCINOEMBRYONIC (CEA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|245||||245|37.92|169.05|15.93
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|AARP [1000]|AARP [100000]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|AETNA [1015]|AETNA [101529]|32||||32|23.09|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|BCBS [1155]|BCBS UTHCT [115568]|32||||32|15.04|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32||||32|25.41|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32||||32|16|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32||||32|20.16|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|CIGNA [1260]|CIGNA GWH [126023]|32||||32|19.54|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|32||||32|22.08|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|32||||32|21.09|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32||||32|23.09|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32||||32|23.09|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|32||||32|22.08|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|Self-pay|Self-pay|32||||32|11.2|25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32||||32||25.41|11.2
30182379|EAP|0301 - LABORATORY-CHEMISTRY|HC CARNITINE (TOTAL & FREE) QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32||||32||25.41|11.2
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|AARP [1000]|AARP [100000]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|AETNA [1015]|AETNA [101529]|19||||19|12.62|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|BCBS [1155]|BCBS UTHCT [115568]|19||||19|8.93|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19||||19|13.9|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19||||19|9.5|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19||||19|11.97|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|CIGNA [1260]|CIGNA GWH [126023]|19||||19|10.78|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|19||||19|13.11|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19||||19|11.53|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19||||19|12.62|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19||||19|12.62|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|19||||19|13.11|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|Self-pay|Self-pay|19||||19|6.65|13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19||||19||13.9|6.65
30182380|EAP|0301 - LABORATORY-CHEMISTRY|HC CAROTENE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19||||19||13.9|6.65
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|AARP [1000]|AARP [100000]|223||||223|35.28|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|223||||223|25.5|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|AETNA [1015]|AETNA [101529]|223||||223|34.54|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|223||||223|21.21|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|223||||223|25.25|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|223||||223|25.25|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|BCBS [1155]|BCBS UTHCT [115568]|223||||223|104.81|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|223||||223|38.04|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|223||||223|111.5|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|223||||223|140.49|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|223||||223|21.21|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|223||||223|25.25|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|CIGNA [1260]|CIGNA GWH [126023]|223||||223|29.46|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|223||||223|153.87|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|223||||223|31.56|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|223||||223|25.25|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|223||||223|34.54|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|223||||223|21.21|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|223||||223|25.25|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|223||||223|34.54|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|223||||223|21.21|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|223||||223|21.21|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|223||||223|153.87|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|223||||223|21.21|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|Self-pay|Self-pay|223||||223|78.05|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|223||||223|21.21|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|223||||223|21.21|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|223||||223|35.28|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|223||||223|25.25|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|223||||223|25.25|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|223||||223|35.28|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|223||||223|25.25|153.87|21.21
30182384|EAP|0301 - LABORATORY-CHEMISTRY|HC CATECHOLAMINES FRACTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|223||||223|50.5|153.87|21.21
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AARP [1000]|AARP [100000]|213||||213|15.01|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|213||||213|10.85|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AETNA [1015]|AETNA [101529]|213||||213|14.69|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|213||||213|9.02|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|213||||213|10.74|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|213||||213|10.74|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BCBS UTHCT [115568]|213||||213|100.11|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|213||||213|16.18|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|213||||213|106.5|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|213||||213|134.19|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|213||||213|9.02|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|213||||213|10.74|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|CIGNA [1260]|CIGNA GWH [126023]|213||||213|12.47|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|213||||213|146.97|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|213||||213|13.43|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|213||||213|10.74|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|213||||213|14.69|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|213||||213|9.02|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|213||||213|10.74|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|213||||213|14.69|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|213||||213|9.02|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|213||||213|9.02|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|213||||213|146.97|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|213||||213|9.02|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|Self-pay|Self-pay|213||||213|74.55|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|213||||213|9.02|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|213||||213|9.02|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|213||||213|15.01|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|213||||213|10.74|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|213||||213|10.74|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|213||||213|15.01|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|213||||213|10.74|146.97|9.02
30182390|EAP|0301 - LABORATORY-CHEMISTRY|HC CERULOPLASMIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|213||||213|21.48|146.97|9.02
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AARP [1000]|AARP [100000]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AETNA [1015]|AETNA [101529]|355||||355|19.32|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BCBS UTHCT [115568]|355||||355|166.85|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|355||||355|21.26|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|355||||355|177.5|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|355||||355|223.65|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|CIGNA [1260]|CIGNA GWH [126023]|355||||355|16.43|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|355||||355|244.95|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|355||||355|17.65|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|355||||355|19.32|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|355||||355|19.32|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|355||||355|244.95|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|Self-pay|Self-pay|355||||355|124.25|244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|355||||355||244.95|16.43
30182397|EAP|0301 - LABORATORY-CHEMISTRY|HC CHEMILUMINESCENT ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|355||||355||244.95|16.43
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AARP [1000]|AARP [100000]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AETNA [1015]|AETNA [101529]|75||||75|6.29|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BCBS UTHCT [115568]|75||||75|35.25|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75||||75|6.93|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75||||75|37.5|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75||||75|47.25|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|CIGNA [1260]|CIGNA GWH [126023]|75||||75|5.39|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|75||||75|51.75|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|75||||75|5.75|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75||||75|6.29|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75||||75|6.29|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|75||||75|51.75|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|Self-pay|Self-pay|75||||75|26.25|51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75||||75||51.75|5.39
30182435|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE BLOOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75||||75||51.75|5.39
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AARP [1000]|AARP [100000]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AETNA [1015]|AETNA [101529]|165||||165|7.87|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS [1155]|BCBS UTHCT [115568]|165||||165|77.55|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|165||||165|7.58|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|165||||165|82.5|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|165||||165|103.95|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|CIGNA [1260]|CIGNA GWH [126023]|165||||165|5.95|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|165||||165|113.85|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|165||||165|7.19|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|165||||165|7.87|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|165||||165|7.87|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|165||||165|113.85|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|Self-pay|Self-pay|165||||165|57.75|113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|165||||165||113.85|5.95
30182436|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|165||||165||113.85|5.95
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|AARP [1000]|AARP [100000]|189||||189|6.83|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189|5.05|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|189||||189|6.84|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189|4.2|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189|5|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189|5|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|7.36|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189|4.2|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189|5|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|5.66|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|6.25|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189|5|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|6.84|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189|4.2|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189|5|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|6.84|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189|4.2|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189|4.2|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189|4.2|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|Self-pay|Self-pay|189||||189|66.15|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189|4.2|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189|4.2|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189|6.83|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189|5|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189|5|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189|6.83|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189|5|130.41|4.2
30182438|EAP|0301 - LABORATORY-CHEMISTRY|HC CHLORIDE OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189|10|130.41|4.2
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AARP [1000]|AARP [100000]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AETNA [1015]|AETNA [101529]|64||||64|5.95|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|64||||64|30.08|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64||||64|6.55|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64||||64|32|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64||||64|40.32|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|64||||64|5.1|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|64||||64|44.16|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|64||||64|5.44|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64||||64|5.95|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64||||64|5.95|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|64||||64|44.16|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|Self-pay|Self-pay|64||||64|22.4|44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64||||64||44.16|5.1
30182465|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLESTEROL SERUM/WHOLE BLOOD TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64||||64||44.16|5.1
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|AARP [1000]|AARP [100000]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|AETNA [1015]|AETNA [101529]|134||||134|10.78|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|BCBS [1155]|BCBS UTHCT [115568]|134||||134|62.98|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|134||||134|11.86|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|134||||134|67|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|134||||134|84.42|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|CIGNA [1260]|CIGNA GWH [126023]|134||||134|9.07|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|134||||134|92.46|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|134||||134|9.84|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|134||||134|10.78|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|134||||134|10.78|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|134||||134|92.46|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|Self-pay|Self-pay|134||||134|46.9|92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|134||||134||92.46|9.07
30182480|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|134||||134||92.46|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|AARP [1000]|AARP [100000]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|AETNA [1015]|AETNA [101529]|246||||246|13.42|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|BCBS [1155]|BCBS UTHCT [115568]|246||||246|115.62|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|246||||246|11.97|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|246||||246|123|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|246||||246|154.98|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|CIGNA [1260]|CIGNA GWH [126023]|246||||246|9.07|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|246||||246|169.74|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|246||||246|12.26|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|246||||246|13.42|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|246||||246|13.42|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|246||||246|169.74|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|Self-pay|Self-pay|246||||246|86.1|169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|246||||246||169.74|9.07
30182482|EAP|0301 - LABORATORY-CHEMISTRY|HC CHOLINESTERASE RBC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|246||||246||169.74|9.07
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|AARP [1000]|AARP [100000]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|AETNA [1015]|AETNA [101529]|163||||163|27.74|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|BCBS [1155]|BCBS UTHCT [115568]|163||||163|76.61|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163||||163|30.55|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163||||163|81.5|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163||||163|102.69|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|CIGNA [1260]|CIGNA GWH [126023]|163||||163|23.52|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163||||163|112.47|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|163||||163|25.35|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163||||163|27.74|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163||||163|27.74|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163||||163|112.47|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|Self-pay|Self-pay|163||||163|57.05|112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163||||163||112.47|23.52
30182495|EAP|0301 - LABORATORY-CHEMISTRY|HC CHROMIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163||||163||112.47|23.52
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|AARP [1000]|AARP [100000]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|AETNA [1015]|AETNA [101529]|407||||407|38.04|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|BCBS [1155]|BCBS UTHCT [115568]|407||||407|191.29|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|407||||407|41.88|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|407||||407|203.5|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|407||||407|256.41|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|CIGNA [1260]|CIGNA GWH [126023]|407||||407|32.3|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|407||||407|280.83|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|407||||407|34.75|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|407||||407|38.04|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|407||||407|38.04|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|407||||407|280.83|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|Self-pay|Self-pay|407||||407|142.45|280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|407||||407||280.83|32.3
30182507|EAP|0301 - LABORATORY-CHEMISTRY|HC CITRATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|407||||407||280.83|32.3
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|AARP [1000]|AARP [100000]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|AETNA [1015]|AETNA [101529]|344||||344|25.56|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|BCBS [1155]|BCBS UTHCT [115568]|344||||344|161.68|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|344||||344|28.15|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|344||||344|172|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|344||||344|216.72|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|CIGNA [1260]|CIGNA GWH [126023]|344||||344|21.82|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|344||||344|237.36|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|344||||344|23.35|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|344||||344|25.56|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|344||||344|25.56|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|344||||344|237.36|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|Self-pay|Self-pay|344||||344|120.4|237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|344||||344||237.36|21.82
30182523|EAP|0301 - LABORATORY-CHEMISTRY|HC COLLAGEN CROSS LINKS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|344||||344||237.36|21.82
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AARP [1000]|AARP [100000]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AETNA [1015]|AETNA [101529]|472||||472|16.97|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BCBS UTHCT [115568]|472||||472|221.84|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|472||||472|18.69|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|472||||472|236|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|472||||472|297.36|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|CIGNA [1260]|CIGNA GWH [126023]|472||||472|14.45|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|472||||472|325.68|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|472||||472|15.51|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|472||||472|16.97|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|472||||472|16.97|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|472||||472|325.68|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|Self-pay|Self-pay|472||||472|165.2|325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|472||||472||325.68|14.45
30182525|EAP|0301 - LABORATORY-CHEMISTRY|HC COPPER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|472||||472||325.68|14.45
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|AARP [1000]|AARP [100000]|128||||128|23.35|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128||||128|16.88|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|AETNA [1015]|AETNA [101529]|128||||128|22.85|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128||||128|14.04|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128||||128|16.71|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128||||128|16.71|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|BCBS [1155]|BCBS UTHCT [115568]|128||||128|60.16|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128||||128|25.17|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128||||128|64|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128||||128|80.64|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128||||128|14.04|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128||||128|16.71|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|CIGNA [1260]|CIGNA GWH [126023]|128||||128|19.54|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|128||||128|88.32|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|128||||128|20.89|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128||||128|16.71|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128||||128|22.85|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128||||128|14.04|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128||||128|16.71|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128||||128|22.85|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128||||128|14.04|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|128||||128|14.04|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|128||||128|88.32|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128||||128|14.04|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|Self-pay|Self-pay|128||||128|44.8|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|128||||128|14.04|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128||||128|14.04|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128||||128|23.35|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|128||||128|16.71|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|128||||128|16.71|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128||||128|23.35|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128||||128|16.71|88.32|14.04
30182530|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128||||128|33.42|88.32|14.04
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AARP [1000]|AARP [100000]|279||||279|22.78|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|279||||279|16.46|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AETNA [1015]|AETNA [101529]|279||||279|22.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|279||||279|13.69|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|279||||279|16.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|279||||279|16.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|279||||279|131.13|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|279||||279|24.55|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|279||||279|139.5|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|279||||279|175.77|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|279||||279|13.69|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|279||||279|16.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|279||||279|18.98|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|279||||279|192.51|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|279||||279|20.38|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|279||||279|16.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|279||||279|22.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|279||||279|13.69|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|279||||279|16.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|279||||279|22.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|279||||279|13.69|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|279||||279|13.69|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|279||||279|192.51|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|279||||279|13.69|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|Self-pay|Self-pay|279||||279|97.65|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|279||||279|13.69|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|279||||279|13.69|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|279||||279|22.78|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|279||||279|16.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|279||||279|16.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|279||||279|22.78|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|279||||279|16.3|192.51|13.69
30182533|EAP|0301 - LABORATORY-CHEMISTRY|HC CORTISOL TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|279||||279|32.6|192.51|13.69
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|AARP [1000]|AARP [100000]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|AETNA [1015]|AETNA [101529]|710||||710|32.95|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|BCBS [1155]|BCBS UTHCT [115568]|710||||710|333.7|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|710||||710|29.39|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|710||||710|355|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|710||||710|447.3|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|CIGNA [1260]|CIGNA GWH [126023]|710||||710|20.96|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|710||||710|489.9|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|710||||710|30.11|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|710||||710|32.95|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|710||||710|32.95|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|710||||710|489.9|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|Self-pay|Self-pay|710||||710|248.5|489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|710||||710||489.9|20.96
30182542|EAP|0301 - LABORATORY-CHEMISTRY|HC COL-CHR/MS NONDRUG ANALYT NES QL/QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|710||||710||489.9|20.96
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AARP [1000]|AARP [100000]|168||||168|9.1|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|168||||168|6.58|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AETNA [1015]|AETNA [101529]|168||||168|8.9|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|168||||168|5.47|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|168||||168|6.51|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|168||||168|6.51|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BCBS UTHCT [115568]|168||||168|78.96|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|168||||168|9.81|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|168||||168|84|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|168||||168|105.84|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|168||||168|5.47|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|168||||168|6.51|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|CIGNA [1260]|CIGNA GWH [126023]|168||||168|7.64|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|168||||168|115.92|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|168||||168|8.14|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|168||||168|6.51|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|168||||168|8.9|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|168||||168|5.47|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|168||||168|6.51|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|168||||168|8.9|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|168||||168|5.47|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|168||||168|5.47|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|168||||168|115.92|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|168||||168|5.47|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|Self-pay|Self-pay|168||||168|58.8|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|168||||168|5.47|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|168||||168|5.47|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|168||||168|9.1|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|168||||168|6.51|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|168||||168|6.51|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|168||||168|9.1|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|168||||168|6.51|115.92|5.47
30182550|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|168||||168|13.02|115.92|5.47
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AARP [1000]|AARP [100000]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AETNA [1015]|AETNA [101529]|227||||227|18.31|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS [1155]|BCBS UTHCT [115568]|227||||227|106.69|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|227||||227|20.17|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|227||||227|113.5|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|227||||227|143.01|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|CIGNA [1260]|CIGNA GWH [126023]|227||||227|15.58|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|GROUP PENSION ADMIN [1450]|GPA [145000]|227||||227|156.63|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|227||||227|16.74|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|227||||227|18.31|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|227||||227|18.31|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|PHCS [1780]|PHCS MULTIPLAN [178000]|227||||227|156.63|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|Self-pay|Self-pay|227||||227|79.45|156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|227||||227||156.63|15.58
30182552|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE ISOENZYME|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|227||||227||156.63|15.58
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AARP [1000]|AARP [100000]|174||||174|16.13|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|174||||174|11.67|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AETNA [1015]|AETNA [101529]|174||||174|15.79|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|174||||174|9.7|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|174||||174|11.55|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|174||||174|11.55|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS [1155]|BCBS UTHCT [115568]|174||||174|81.78|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|174||||174|17.4|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|174||||174|87|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|174||||174|109.62|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|174||||174|9.7|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|174||||174|11.55|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|CIGNA [1260]|CIGNA GWH [126023]|174||||174|13.32|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|174||||174|120.06|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|174||||174|14.44|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|174||||174|11.55|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|174||||174|15.79|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|174||||174|9.7|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|174||||174|11.55|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|174||||174|15.79|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|174||||174|9.7|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|174||||174|9.7|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|174||||174|120.06|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|174||||174|9.7|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|Self-pay|Self-pay|174||||174|60.9|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|174||||174|9.7|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|174||||174|9.7|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|174||||174|16.13|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|174||||174|11.55|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|174||||174|11.55|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|174||||174|16.13|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|174||||174|11.55|120.06|9.7
30182553|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATINE KINASE (CPK) MB ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|174||||174|23.1|120.06|9.7
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AARP [1000]|AARP [100000]|92||||92|7.16|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92||||92|5.17|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AETNA [1015]|AETNA [101529]|92||||92|7.01|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92||||92|4.3|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92||||92|5.12|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92||||92|5.12|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BCBS UTHCT [115568]|92||||92|43.24|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92||||92|7.72|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92||||92|46|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92||||92|57.96|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92||||92|4.3|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92||||92|5.12|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|CIGNA [1260]|CIGNA GWH [126023]|92||||92|5.95|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|92||||92|63.48|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|92||||92|6.4|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92||||92|5.12|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92||||92|7.01|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92||||92|4.3|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92||||92|5.12|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92||||92|7.01|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92||||92|4.3|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|92||||92|4.3|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|92||||92|63.48|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92||||92|4.3|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|Self-pay|Self-pay|92||||92|32.2|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|92||||92|4.3|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92||||92|4.3|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92||||92|7.16|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|92||||92|5.12|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|92||||92|5.12|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92||||92|7.16|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92||||92|5.12|63.48|4.3
30182565|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92||||92|10.24|63.48|4.3
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AARP [1000]|AARP [100000]|181||||181|7.23|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181||||181|5.23|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|181||||181|7.08|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181||||181|4.35|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181||||181|5.18|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181||||181|5.18|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BCBS UTHCT [115568]|181||||181|85.07|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181||||181|7.8|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181||||181|90.5|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181||||181|114.03|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181||||181|4.35|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181||||181|5.18|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|CIGNA [1260]|CIGNA GWH [126023]|181||||181|9.52|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|181||||181|124.89|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|181||||181|6.48|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181||||181|5.18|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181||||181|7.08|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181||||181|4.35|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181||||181|5.18|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181||||181|7.08|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181||||181|4.35|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|181||||181|4.35|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|181||||181|124.89|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181||||181|4.35|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|Self-pay|Self-pay|181||||181|63.35|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|181||||181|4.35|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181||||181|4.35|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181||||181|7.23|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|181||||181|5.18|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|181||||181|5.18|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181||||181|7.23|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181||||181|5.18|124.89|4.35
30182570|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181||||181|10.36|124.89|4.35
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AARP [1000]|AARP [100000]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AETNA [1015]|AETNA [101529]|154||||154|12.94|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS [1155]|BCBS UTHCT [115568]|154||||154|72.38|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|154||||154|14.24|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|154||||154|77|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|154||||154|97.02|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|CIGNA [1260]|CIGNA GWH [126023]|154||||154|11.04|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|154||||154|106.26|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|154||||154|11.83|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|154||||154|12.94|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|154||||154|12.94|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|154||||154|106.26|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|Self-pay|Self-pay|154||||154|53.9|106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|154||||154||106.26|11.04
30182575|EAP|0301 - LABORATORY-CHEMISTRY|HC CREATININE CLEARANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|154||||154||106.26|11.04
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|AARP [1000]|AARP [100000]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|AETNA [1015]|AETNA [101529]|54||||54|19.34|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|BCBS [1155]|BCBS UTHCT [115568]|54||||54|25.38|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54||||54|17.25|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54||||54|27|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54||||54|34.02|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|CIGNA [1260]|CIGNA GWH [126023]|54||||54|9.92|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54||||54|37.26|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54||||54|17.68|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54||||54|19.34|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54||||54|19.34|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54||||54|37.26|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|Self-pay|Self-pay|54||||54|18.9|37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54||||54||37.26|9.92
30182585|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOFIBRINOGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54||||54||37.26|9.92
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AARP [1000]|AARP [100000]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AETNA [1015]|AETNA [101529]|14||||14|8.86|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BCBS UTHCT [115568]|14||||14|6.58|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14||||14|9.74|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14||||14|7|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14||||14|8.82|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|CIGNA [1260]|CIGNA GWH [126023]|14||||14|7.64|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14||||14|9.66|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14||||14|8.09|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14||||14|8.86|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14||||14|8.86|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14||||14|9.66|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|Self-pay|Self-pay|14||||14|4.9|9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14||||14||9.74|4.9
30182595|EAP|0301 - LABORATORY-CHEMISTRY|HC CRYOGLOBULINS QL/SEMI-QUANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14||||14||9.74|4.9
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|AARP [1000]|AARP [100000]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|AETNA [1015]|AETNA [101529]|109||||109|26.54|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|BCBS [1155]|BCBS UTHCT [115568]|109||||109|51.23|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109||||109|29.22|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109||||109|54.5|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109||||109|68.67|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|CIGNA [1260]|CIGNA GWH [126023]|109||||109|22.67|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|109||||109|75.21|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|109||||109|24.25|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109||||109|26.54|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109||||109|26.54|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|109||||109|75.21|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|Self-pay|Self-pay|109||||109|38.15|75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109||||109||75.21|22.67
30182600|EAP|0301 - LABORATORY-CHEMISTRY|HC CYANIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|109||||109||75.21|22.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AARP [1000]|AARP [100000]|188||||188|21.06|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|188||||188|15.23|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AETNA [1015]|AETNA [101529]|188||||188|20.64|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|188||||188|12.67|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|188||||188|15.08|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|188||||188|15.08|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BCBS UTHCT [115568]|188||||188|88.36|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|188||||188|22.7|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|188||||188|94|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|188||||188|118.44|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|188||||188|12.67|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|188||||188|15.08|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|CIGNA [1260]|CIGNA GWH [126023]|188||||188|17.57|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|GROUP PENSION ADMIN [1450]|GPA [145000]|188||||188|129.72|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|188||||188|18.85|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|188||||188|15.08|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|188||||188|20.64|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|188||||188|12.67|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|188||||188|15.08|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|188||||188|20.64|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|188||||188|12.67|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|188||||188|12.67|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|PHCS [1780]|PHCS MULTIPLAN [178000]|188||||188|129.72|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|188||||188|12.67|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|Self-pay|Self-pay|188||||188|65.8|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|188||||188|12.67|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|188||||188|12.67|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|188||||188|21.06|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|188||||188|15.08|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|188||||188|15.08|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|188||||188|21.06|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|188||||188|15.08|129.72|12.67
30182607|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B12|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|188||||188|30.16|129.72|12.67
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|AARP [1000]|AARP [100000]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|AETNA [1015]|AETNA [101529]|253||||253|25.34|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|BCBS [1155]|BCBS UTHCT [115568]|253||||253|118.91|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|253||||253|22.59|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|253||||253|126.5|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|253||||253|159.39|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|CIGNA [1260]|CIGNA GWH [126023]|253||||253|15.86|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|253||||253|174.57|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|253||||253|23.15|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|253||||253|25.34|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|253||||253|25.34|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|253||||253|174.57|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|Self-pay|Self-pay|253||||253|88.55|174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|253||||253||174.57|15.86
30182610|EAP|0301 - LABORATORY-CHEMISTRY|HC CYSTATIN C|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|253||||253||174.57|15.86
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|AARP [1000]|AARP [100000]|55||||55|35.31|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|55||||55|25.52|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|AETNA [1015]|AETNA [101529]|55||||55|34.56|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55||||55|21.23|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55||||55|25.27|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|55||||55|25.27|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|BCBS [1155]|BCBS UTHCT [115568]|55||||55|25.85|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|55||||55|38.06|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|55||||55|27.5|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|55||||55|34.65|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|55||||55|21.23|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|55||||55|25.27|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|CIGNA [1260]|CIGNA GWH [126023]|55||||55|29.46|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|55||||55|37.95|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|55||||55|31.59|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|55||||55|25.27|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55||||55|34.56|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|55||||55|21.23|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|55||||55|25.27|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55||||55|34.56|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|55||||55|21.23|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|55||||55|21.23|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|55||||55|37.95|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|55||||55|21.23|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|Self-pay|Self-pay|55||||55|19.25|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|55||||55|21.23|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|55||||55|21.23|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55||||55|35.31|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|55||||55|25.27|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|55||||55|25.27|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|55||||55|35.31|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|55||||55|25.27|50.54|19.25
30182626|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|55||||55|50.54|50.54|19.25
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|AARP [1000]|AARP [100000]|49||||49|31.07|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49||||49|22.45|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|AETNA [1015]|AETNA [101529]|49||||49|30.41|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49||||49|18.67|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49||||49|22.23|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49||||49|22.23|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|BCBS [1155]|BCBS UTHCT [115568]|49||||49|23.03|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49||||49|33.49|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49||||49|24.5|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49||||49|30.87|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49||||49|18.67|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49||||49|22.23|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|CIGNA [1260]|CIGNA GWH [126023]|49||||49|25.78|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|GROUP PENSION ADMIN [1450]|GPA [145000]|49||||49|33.81|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|49||||49|27.79|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49||||49|22.23|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49||||49|30.41|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49||||49|18.67|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49||||49|22.23|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49||||49|30.41|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49||||49|18.67|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|49||||49|18.67|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|PHCS [1780]|PHCS MULTIPLAN [178000]|49||||49|33.81|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49||||49|18.67|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|Self-pay|Self-pay|49||||49|17.15|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|49||||49|18.67|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49||||49|18.67|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49||||49|31.07|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|49||||49|22.23|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|49||||49|22.23|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49||||49|31.07|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49||||49|22.23|44.46|17.15
30182627|EAP|0301 - LABORATORY-CHEMISTRY|HC DHEA-S|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49||||49|44.46|44.46|17.15
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|AARP [1000]|AARP [100000]|794.5||||794.5|40.9|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|794.5||||794.5|29.57|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|AETNA [1015]|AETNA [101529]|794.5||||794.5|40.06|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|794.5||||794.5|24.6|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|794.5||||794.5|29.28|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|794.5||||794.5|29.28|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|BCBS [1155]|BCBS UTHCT [115568]|794.5||||794.5|373.42|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|794.5||||794.5|44.09|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|794.5||||794.5|397.25|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|794.5||||794.5|500.54|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|794.5||||794.5|24.6|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|794.5||||794.5|29.28|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|CIGNA [1260]|CIGNA GWH [126023]|794.5||||794.5|34|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|794.5||||794.5|548.21|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|794.5||||794.5|36.6|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|794.5||||794.5|29.28|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|794.5||||794.5|40.06|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|794.5||||794.5|24.6|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|794.5||||794.5|29.28|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|794.5||||794.5|40.06|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|794.5||||794.5|24.6|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|794.5||||794.5|24.6|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|794.5||||794.5|548.21|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|794.5||||794.5|24.6|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|Self-pay|Self-pay|794.5||||794.5|278.07|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|794.5||||794.5|24.6|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|794.5||||794.5|24.6|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|794.5||||794.5|40.9|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|794.5||||794.5|29.28|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|794.5||||794.5|29.28|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|794.5||||794.5|40.9|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|794.5||||794.5|29.28|548.21|24.6
30182634|EAP|0301 - LABORATORY-CHEMISTRY|HC DEOXYCORTISOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|794.5||||794.5|58.56|548.21|24.6
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AARP [1000]|AARP [100000]|628||||628|53.78|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|628||||628|38.89|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AETNA [1015]|AETNA [101529]|628||||628|52.68|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|628||||628|32.34|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|628||||628|38.5|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|628||||628|38.5|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BCBS UTHCT [115568]|628||||628|295.16|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|628||||628|57.99|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|628||||628|314|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|628||||628|395.64|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|628||||628|32.34|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|628||||628|38.5|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|CIGNA [1260]|CIGNA GWH [126023]|628||||628|44.76|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|628||||628|433.32|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|628||||628|48.13|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|628||||628|38.5|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|628||||628|52.68|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|628||||628|32.34|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|628||||628|38.5|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|628||||628|52.68|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|628||||628|32.34|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|628||||628|32.34|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|628||||628|433.32|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|628||||628|32.34|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|Self-pay|Self-pay|628||||628|219.8|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|628||||628|32.34|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|628||||628|32.34|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|628||||628|53.78|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|628||||628|38.5|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|628||||628|38.5|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|628||||628|53.78|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|628||||628|38.5|433.32|32.34
30182652|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN D (1,25 DIHYDROXY)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|628||||628|77|433.32|32.34
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|AARP [1000]|AARP [100000]|637||||637|25.23|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|637||||637|22.39|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|AETNA [1015]|AETNA [101529]|637||||637|30.34|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|637||||637|18.62|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|637||||637|22.17|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|637||||637|22.17|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|BCBS [1155]|BCBS UTHCT [115568]|637||||637|299.39|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|637||||637|27.19|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|637||||637|318.5|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|637||||637|401.31|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|637||||637|18.62|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|637||||637|22.17|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|CIGNA [1260]|CIGNA GWH [126023]|637||||637|20.96|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|637||||637|439.53|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|637||||637|27.71|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|637||||637|22.17|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|637||||637|30.34|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|637||||637|18.62|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|637||||637|22.17|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|637||||637|30.34|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|637||||637|18.62|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|637||||637|18.62|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|637||||637|439.53|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|637||||637|18.62|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|Self-pay|Self-pay|637||||637|222.95|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|637||||637|18.62|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|637||||637|18.62|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|637||||637|25.23|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|637||||637|22.17|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|637||||637|22.17|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|637||||637|25.23|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|637||||637|22.17|439.53|18.62
30182657|EAP|0301 - LABORATORY-CHEMISTRY|HC NZYM ACTIV BLD CELLS/TISS NONRADACT SUBSTRATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|637||||637|44.34|439.53|18.62
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|AARP [1000]|AARP [100000]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|AETNA [1015]|AETNA [101529]|99||||99|84.14|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|BCBS [1155]|BCBS UTHCT [115568]|99||||99|46.53|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99||||99|75.03|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99||||99|49.5|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99||||99|62.37|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|CIGNA [1260]|CIGNA GWH [126023]|99||||99|39.95|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|99||||99|68.31|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|99||||99|76.88|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99||||99|84.14|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99||||99|84.14|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|99||||99|68.31|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|Self-pay|Self-pay|99||||99|34.65|84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99||||99||84.14|34.65
30182664|EAP|0301 - LABORATORY-CHEMISTRY|HC ELECTROPHORETIC TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99||||99||84.14|34.65
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AARP [1000]|AARP [100000]|318||||318|26.26|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|318||||318|18.98|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AETNA [1015]|AETNA [101529]|318||||318|25.7|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|318||||318|15.78|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|318||||318|18.79|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|318||||318|18.79|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BCBS UTHCT [115568]|318||||318|149.46|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|318||||318|28.3|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|318||||318|159|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|318||||318|200.34|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|318||||318|15.78|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|318||||318|18.79|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|CIGNA [1260]|CIGNA GWH [126023]|318||||318|21.82|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|318||||318|219.42|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|318||||318|23.49|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|318||||318|18.79|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|318||||318|25.7|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|318||||318|15.78|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|318||||318|18.79|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|318||||318|25.7|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|318||||318|15.78|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|318||||318|15.78|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|318||||318|219.42|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|318||||318|15.78|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|Self-pay|Self-pay|318||||318|111.3|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|318||||318|15.78|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|318||||318|15.78|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|318||||318|26.26|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|318||||318|18.79|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|318||||318|18.79|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|318||||318|26.26|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|318||||318|18.79|219.42|15.78
30182668|EAP|0301 - LABORATORY-CHEMISTRY|HC ERYTHROPOIETIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|318||||318|37.58|219.42|15.78
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|AARP [1000]|AARP [100000]|254||||254|39.04|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|254||||254|28.22|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|AETNA [1015]|AETNA [101529]|254||||254|38.23|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|254||||254|23.47|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|254||||254|27.94|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|254||||254|27.94|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|BCBS [1155]|BCBS UTHCT [115568]|254||||254|119.38|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|254||||254|42.08|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|254||||254|127|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|254||||254|160.02|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|254||||254|23.47|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|254||||254|27.94|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|CIGNA [1260]|CIGNA GWH [126023]|254||||254|32.57|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|254||||254|175.26|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|254||||254|34.93|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|254||||254|27.94|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|254||||254|38.23|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|254||||254|23.47|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|254||||254|27.94|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|254||||254|38.23|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|254||||254|23.47|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|254||||254|23.47|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|254||||254|175.26|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|254||||254|23.47|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|Self-pay|Self-pay|254||||254|88.9|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|254||||254|23.47|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|254||||254|23.47|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|254||||254|39.04|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|254||||254|27.94|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|254||||254|27.94|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|254||||254|39.04|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|254||||254|27.94|175.26|23.47
30182670|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL ESTRADIOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|254||||254|55.88|175.26|23.47
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|AARP [1000]|AARP [100000]|690||||690|45.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|690||||690|32.62|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|AETNA [1015]|AETNA [101529]|690||||690|44.18|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|690||||690|27.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|690||||690|32.3|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|690||||690|32.3|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|BCBS [1155]|BCBS UTHCT [115568]|690||||690|324.3|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|690||||690|48.65|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|690||||690|345|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|690||||690|434.7|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|690||||690|27.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|690||||690|32.3|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|CIGNA [1260]|CIGNA GWH [126023]|690||||690|37.39|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|690||||690|476.1|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|690||||690|40.38|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|690||||690|32.3|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|690||||690|44.18|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|690||||690|27.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|690||||690|32.3|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|690||||690|44.18|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|690||||690|27.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|690||||690|27.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|690||||690|476.1|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|690||||690|27.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|Self-pay|Self-pay|690||||690|241.5|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|690||||690|27.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|690||||690|27.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|690||||690|45.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|690||||690|32.3|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|690||||690|32.3|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|690||||690|45.13|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|690||||690|32.3|476.1|27.13
30182671|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTROGENS FRACTIONATED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|690||||690|64.6|476.1|27.13
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|AARP [1000]|AARP [100000]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|AETNA [1015]|AETNA [101529]|111||||111|33.07|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|BCBS [1155]|BCBS UTHCT [115568]|111||||111|52.17|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111||||111|36.42|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111||||111|55.5|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111||||111|69.93|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|CIGNA [1260]|CIGNA GWH [126023]|111||||111|28.06|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|111||||111|76.59|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|111||||111|30.23|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111||||111|33.07|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111||||111|33.07|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|111||||111|76.59|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|Self-pay|Self-pay|111||||111|38.85|76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111||||111||76.59|28.06
30182677|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRIOL SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111||||111||76.59|28.06
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|AARP [1000]|AARP [100000]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|AETNA [1015]|AETNA [101529]|105||||105|34.13|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|BCBS [1155]|BCBS UTHCT [115568]|105||||105|49.35|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105||||105|37.59|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105||||105|52.5|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105||||105|66.15|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|CIGNA [1260]|CIGNA GWH [126023]|105||||105|28.9|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|105||||105|72.45|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105||||105|31.19|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105||||105|34.13|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105||||105|34.13|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|105||||105|72.45|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|Self-pay|Self-pay|105||||105|36.75|72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105||||105||72.45|28.9
30182679|EAP|0301 - LABORATORY-CHEMISTRY|HC ESTRONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105||||105||72.45|28.9
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|AARP [1000]|AARP [100000]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|AETNA [1015]|AETNA [101529]|37||||37|20.38|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|BCBS [1155]|BCBS UTHCT [115568]|37||||37|17.39|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37||||37|22.45|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37||||37|18.5|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37||||37|23.31|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|CIGNA [1260]|CIGNA GWH [126023]|37||||37|17.28|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|37||||37|25.53|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|37||||37|18.63|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37||||37|20.38|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37||||37|20.38|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|37||||37|25.53|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|Self-pay|Self-pay|37||||37|12.95|25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37||||37||25.53|12.95
30182693|EAP|0301 - LABORATORY-CHEMISTRY|HC ETHYLENE GLYCOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37||||37||25.53|12.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AARP [1000]|AARP [100000]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AETNA [1015]|AETNA [101529]|58||||58|6.98|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS [1155]|BCBS UTHCT [115568]|58||||58|27.26|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58||||58|7.67|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58||||58|29|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58||||58|36.54|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|CIGNA [1260]|CIGNA GWH [126023]|58||||58|5.95|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|58||||58|40.02|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58||||58|6.38|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58||||58|6.98|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58||||58|6.98|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|58||||58|40.02|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|Self-pay|Self-pay|58||||58|20.3|40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58||||58||40.02|5.95
30182705|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58||||58||40.02|5.95
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|AARP [1000]|AARP [100000]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|AETNA [1015]|AETNA [101529]|146||||146|22.99|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|BCBS [1155]|BCBS UTHCT [115568]|146||||146|68.62|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|25.32|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|91.98|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|CIGNA [1260]|CIGNA GWH [126023]|146||||146|19.54|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|146||||146|21|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|22.99|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|22.99|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|Self-pay|Self-pay|146||||146|51.1|100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146||100.74|19.54
30182710|EAP|0301 - LABORATORY-CHEMISTRY|HC FAT/LIPIDS FECES QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146||||146||100.74|19.54
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AARP [1000]|AARP [100000]|182.99||||182.99|19.03|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182.99||||182.99|13.77|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AETNA [1015]|AETNA [101529]|182.99||||182.99|18.65|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182.99||||182.99|11.45|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182.99||||182.99|13.63|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182.99||||182.99|13.63|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BCBS UTHCT [115568]|182.99||||182.99|86.01|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182.99||||182.99|20.53|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182.99||||182.99|91.5|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182.99||||182.99|115.28|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182.99||||182.99|11.45|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182.99||||182.99|13.63|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|CIGNA [1260]|CIGNA GWH [126023]|182.99||||182.99|15.86|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182.99||||182.99|126.26|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|182.99||||182.99|17.04|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182.99||||182.99|13.63|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182.99||||182.99|18.65|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182.99||||182.99|11.45|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182.99||||182.99|13.63|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182.99||||182.99|18.65|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182.99||||182.99|11.45|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|182.99||||182.99|11.45|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182.99||||182.99|126.26|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182.99||||182.99|11.45|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|Self-pay|Self-pay|182.99||||182.99|64.05|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|182.99||||182.99|11.45|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182.99||||182.99|11.45|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182.99||||182.99|19.03|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|182.99||||182.99|13.63|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|182.99||||182.99|13.63|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182.99||||182.99|19.03|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182.99||||182.99|13.63|126.26|11.45
30182728|EAP|0301 - LABORATORY-CHEMISTRY|HC FERRITIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182.99||||182.99|27.26|126.26|11.45
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AARP [1000]|AARP [100000]|173||||173|20.54|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|173||||173|14.85|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AETNA [1015]|AETNA [101529]|173||||173|20.11|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|173||||173|12.35|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|173||||173|14.7|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|173||||173|14.7|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BCBS UTHCT [115568]|173||||173|81.31|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|173||||173|22.14|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|173||||173|86.5|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|173||||173|108.99|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|173||||173|12.35|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|173||||173|14.7|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|CIGNA [1260]|CIGNA GWH [126023]|173||||173|16.99|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|173||||173|119.37|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|173||||173|18.38|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|173||||173|14.7|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|173||||173|20.11|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|173||||173|12.35|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|173||||173|14.7|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|173||||173|20.11|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|173||||173|12.35|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|173||||173|12.35|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|173||||173|119.37|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|173||||173|12.35|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|Self-pay|Self-pay|173||||173|60.55|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|173||||173|12.35|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|173||||173|12.35|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|173||||173|20.54|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|173||||173|14.7|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|173||||173|14.7|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|173||||173|20.54|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|173||||173|14.7|119.37|12.35
30182746|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|173||||173|29.4|119.37|12.35
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AARP [1000]|AARP [100000]|216||||216|24.2|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216|17.83|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AETNA [1015]|AETNA [101529]|216||||216|24.14|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|14.83|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216|17.65|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216|17.65|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|26.08|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|14.83|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216|17.65|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|20.11|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|22.06|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216|17.65|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|24.14|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|14.83|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216|17.65|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|24.14|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|14.83|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|14.83|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|14.83|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|Self-pay|Self-pay|216||||216|75.6|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|14.83|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|14.83|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216|24.2|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216|17.65|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216|17.65|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216|24.2|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216|17.65|149.04|14.83
30182747|EAP|0301 - LABORATORY-CHEMISTRY|HC FOLIC ACID RBC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216|35.3|149.04|14.83
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|AARP [1000]|AARP [100000]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|AETNA [1015]|AETNA [101529]|221||||221|28.82|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|BCBS [1155]|BCBS UTHCT [115568]|221||||221|103.87|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|221||||221|31.73|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|221||||221|110.5|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|221||||221|139.23|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|CIGNA [1260]|CIGNA GWH [126023]|221||||221|24.36|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|221||||221|152.49|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|221||||221|26.34|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|221||||221|28.82|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|221||||221|28.82|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|221||||221|152.49|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|Self-pay|Self-pay|221||||221|77.35|152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|221||||221||152.49|24.36
30182775|EAP|0301 - LABORATORY-CHEMISTRY|HC G-1-PU W/GENOTYPING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|221||||221||152.49|24.36
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AARP [1000]|AARP [100000]|297||||297|12.99|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|297||||297|9.39|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AETNA [1015]|AETNA [101529]|297||||297|12.72|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|297||||297|7.81|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|297||||297|9.3|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|297||||297|9.3|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BCBS UTHCT [115568]|297||||297|139.59|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|297||||297|14.01|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|297||||297|148.5|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|297||||297|187.11|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|297||||297|7.81|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|297||||297|9.3|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|CIGNA [1260]|CIGNA GWH [126023]|297||||297|10.78|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|297||||297|204.93|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|297||||297|11.63|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|297||||297|9.3|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|297||||297|12.72|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|297||||297|7.81|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|297||||297|9.3|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|297||||297|12.72|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|297||||297|7.81|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|297||||297|7.81|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|297||||297|204.93|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|297||||297|7.81|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|Self-pay|Self-pay|297||||297|103.95|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|297||||297|7.81|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|297||||297|7.81|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|297||||297|12.99|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|297||||297|9.3|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|297||||297|9.3|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|297||||297|12.99|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|297||||297|9.3|204.93|7.81
30182784|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGA/IGD/IGG/IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|297||||297|18.6|204.93|7.81
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AARP [1000]|AARP [100000]|235||||235|23.01|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|235||||235|16.62|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AETNA [1015]|AETNA [101529]|235||||235|22.51|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|235||||235|13.83|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|235||||235|16.46|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|235||||235|16.46|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BCBS UTHCT [115568]|235||||235|110.45|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|235||||235|24.79|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|235||||235|117.5|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|235||||235|148.05|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|235||||235|13.83|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|235||||235|16.46|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|CIGNA [1260]|CIGNA GWH [126023]|235||||235|19.27|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|235||||235|162.15|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|235||||235|20.58|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|235||||235|16.46|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|235||||235|22.51|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|235||||235|13.83|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|235||||235|16.46|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|235||||235|22.51|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|235||||235|13.83|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|235||||235|13.83|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|235||||235|162.15|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|235||||235|13.83|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|Self-pay|Self-pay|235||||235|82.25|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|235||||235|13.83|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|235||||235|13.83|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|235||||235|23.01|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|235||||235|16.46|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|235||||235|16.46|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|235||||235|23.01|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|235||||235|16.46|162.15|13.83
30182785|EAP|0301 - LABORATORY-CHEMISTRY|HC GAMMAGLOBULIN IGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|235||||235|32.92|162.15|13.83
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AARP [1000]|AARP [100000]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AETNA [1015]|AETNA [101529]|16||||16|10.97|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS [1155]|BCBS UTHCT [115568]|16||||16|7.52|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16||||16|12.08|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16||||16|8|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16||||16|10.08|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|CIGNA [1260]|CIGNA GWH [126023]|16||||16|9.35|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|16||||16|11.04|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16||||16|10.03|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16||||16|10.97|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16||||16|10.97|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|16||||16|11.04|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|Self-pay|Self-pay|16||||16|5.6|12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16||||16||12.08|5.6
30182787|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOGLOB SUBCLASSES EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16||||16||12.08|5.6
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AARP [1000]|AARP [100000]|444||||444|27.04|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|444||||444|26.33|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AETNA [1015]|AETNA [101529]|444||||444|35.66|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|444||||444|21.9|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|444||||444|26.07|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|444||||444|26.07|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BCBS UTHCT [115568]|444||||444|208.68|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|444||||444|31.81|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|444||||444|222|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|444||||444|279.72|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|444||||444|21.9|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|444||||444|26.07|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|CIGNA [1260]|CIGNA GWH [126023]|444||||444|35.81|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|GROUP PENSION ADMIN [1450]|GPA [145000]|444||||444|306.36|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|444||||444|32.59|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|444||||444|26.07|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|444||||444|35.66|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|444||||444|21.9|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|444||||444|26.07|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|444||||444|35.66|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|444||||444|21.9|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|444||||444|21.9|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|PHCS [1780]|PHCS MULTIPLAN [178000]|444||||444|306.36|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|444||||444|21.9|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|Self-pay|Self-pay|444||||444|155.4|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|444||||444|21.9|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|444||||444|21.9|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|444||||444|27.04|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|444||||444|26.07|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|444||||444|26.07|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|444||||444|27.04|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|444||||444|26.07|306.36|21.9
30182803|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS VEN/ART PH P02 &/OR PC02|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|444||||444|52.14|306.36|21.9
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AARP [1000]|AARP [100000]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AETNA [1015]|AETNA [101529]|539||||539|107.76|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS [1155]|BCBS UTHCT [115568]|539||||539|253.33|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|539||||539|96.1|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|539||||539|269.5|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|539||||539|339.57|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|CIGNA [1260]|CIGNA GWH [126023]|539||||539|52.57|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|539||||539|371.91|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|539||||539|98.46|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|539||||539|107.76|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|539||||539|107.76|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|539||||539|371.91|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|Self-pay|Self-pay|539||||539|188.65|371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|539||||539||371.91|52.57
30182805|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS W/02 SAT AND DIRECT MEASURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|539||||539||371.91|52.57
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|AARP [1000]|AARP [100000]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|AETNA [1015]|AETNA [101529]|318||||318|13.37|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|BCBS [1155]|BCBS UTHCT [115568]|318||||318|149.46|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|318||||318|13.14|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|318||||318|159|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|318||||318|200.34|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|CIGNA [1260]|CIGNA GWH [126023]|318||||318|16.32|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|318||||318|219.42|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|318||||318|12.21|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|318||||318|13.37|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|318||||318|13.37|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|318||||318|219.42|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|Self-pay|Self-pay|318||||318|111.3|219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|318||||318||219.42|12.21
30182810|EAP|0301 - LABORATORY-CHEMISTRY|HC BLD GAS O2 SAT ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|318||||318||219.42|12.21
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|AARP [1000]|AARP [100000]|234||||234|24.64|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|234||||234|17.81|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|AETNA [1015]|AETNA [101529]|234||||234|24.12|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|234||||234|14.81|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|234||||234|17.63|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|234||||234|17.63|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|BCBS [1155]|BCBS UTHCT [115568]|234||||234|109.98|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|234||||234|26.56|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|234||||234|117|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|234||||234|147.42|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|234||||234|14.81|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|234||||234|17.63|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|CIGNA [1260]|CIGNA GWH [126023]|234||||234|20.39|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|234||||234|161.46|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|234||||234|22.04|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|234||||234|17.63|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|234||||234|24.12|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|234||||234|14.81|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|234||||234|17.63|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|234||||234|24.12|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|234||||234|14.81|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|234||||234|14.81|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|234||||234|161.46|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|234||||234|14.81|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|Self-pay|Self-pay|234||||234|81.9|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|234||||234|14.81|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|234||||234|14.81|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|234||||234|24.64|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|234||||234|17.63|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|234||||234|17.63|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|234||||234|24.64|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|234||||234|17.63|161.46|14.81
30182941|EAP|0301 - LABORATORY-CHEMISTRY|HC GASTRIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|234||||234|35.26|161.46|14.81
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|AARP [1000]|AARP [100000]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|AETNA [1015]|AETNA [101529]|93||||93|19.56|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|BCBS [1155]|BCBS UTHCT [115568]|93||||93|43.71|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|21.52|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|46.5|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|58.59|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|CIGNA [1260]|CIGNA GWH [126023]|93||||93|16.72|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|93||||93|17.86|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|19.56|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|19.56|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|Self-pay|Self-pay|93||||93|32.55|64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93||64.17|16.72
30182943|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCAGON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93||64.17|16.72
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AARP [1000]|AARP [100000]|119||||119|5.48|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|119||||119|3.97|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AETNA [1015]|AETNA [101529]|119||||119|5.38|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|119||||119|3.3|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|119||||119|3.93|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|119||||119|3.93|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS [1155]|BCBS UTHCT [115568]|119||||119|55.93|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|119||||119|5.92|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|119||||119|59.5|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|119||||119|74.97|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|119||||119|3.3|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|119||||119|3.93|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|CIGNA [1260]|CIGNA GWH [126023]|119||||119|4.54|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|119||||119|82.11|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|119||||119|4.91|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|119||||119|3.93|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|119||||119|5.38|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|119||||119|3.3|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|119||||119|3.93|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|119||||119|5.38|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|119||||119|3.3|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|119||||119|3.3|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|119||||119|82.11|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|119||||119|3.3|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|Self-pay|Self-pay|119||||119|41.65|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|119||||119|3.3|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|119||||119|3.3|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|119||||119|5.48|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|119||||119|3.93|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|119||||119|3.93|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|119||||119|5.48|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|119||||119|3.93|82.11|3.3
30182945|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BODY FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|119||||119|7.86|82.11|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AARP [1000]|AARP [100000]|107||||107|5.48|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|107||||107|3.97|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AETNA [1015]|AETNA [101529]|107||||107|5.38|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|107||||107|3.3|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|107||||107|3.93|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|107||||107|3.93|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BCBS UTHCT [115568]|107||||107|50.29|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|107||||107|5.92|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|107||||107|53.5|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|107||||107|67.41|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|107||||107|3.3|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|107||||107|3.93|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|CIGNA [1260]|CIGNA GWH [126023]|107||||107|7.26|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|107||||107|73.83|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|107||||107|4.91|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|107||||107|3.93|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|107||||107|5.38|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|107||||107|3.3|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|107||||107|3.93|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|107||||107|5.38|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|107||||107|3.3|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|107||||107|3.3|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|107||||107|73.83|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|107||||107|3.3|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|Self-pay|Self-pay|107||||107|37.45|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|107||||107|3.3|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|107||||107|3.3|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|107||||107|5.48|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|107||||107|3.93|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|107||||107|3.93|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|107||||107|5.48|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|107||||107|3.93|73.83|3.3
30182947|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|107||||107|7.86|73.83|3.3
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|AARP [1000]|AARP [100000]|107||||107|4.43|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|107||||107|5.09|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|AETNA [1015]|AETNA [101529]|107||||107|6.89|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|107||||107|4.23|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|107||||107|5.04|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|107||||107|5.04|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|BCBS [1155]|BCBS UTHCT [115568]|107||||107|50.29|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|107||||107|6.15|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|107||||107|53.5|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|107||||107|67.41|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|107||||107|4.23|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|107||||107|5.04|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|CIGNA [1260]|CIGNA GWH [126023]|107||||107|5.89|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|107||||107|73.83|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|107||||107|6.3|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|107||||107|5.04|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|107||||107|6.89|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|107||||107|4.23|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|107||||107|5.04|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|107||||107|6.89|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|107||||107|4.23|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|107||||107|4.23|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|107||||107|73.83|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|107||||107|4.23|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|Self-pay|Self-pay|107||||107|37.45|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|107||||107|4.23|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|107||||107|4.23|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|107||||107|4.43|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|107||||107|5.04|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|107||||107|5.04|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|107||||107|4.43|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|107||||107|5.04|73.83|4.23
30182948|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD REAGENT STRIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|107||||107|10.08|73.83|4.23
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|AARP [1000]|AARP [100000]|38||||38|17.99|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38||||38|13|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|AETNA [1015]|AETNA [101529]|38||||38|17.62|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38||||38|10.81|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38||||38|12.87|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38||||38|12.87|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|BCBS [1155]|BCBS UTHCT [115568]|38||||38|17.86|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38||||38|19.39|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38||||38|19|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38||||38|23.94|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38||||38|10.81|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38||||38|12.87|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|CIGNA [1260]|CIGNA GWH [126023]|38||||38|24.02|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|38||||38|26.22|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|38||||38|16.09|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38||||38|12.87|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38||||38|17.62|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38||||38|10.81|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38||||38|12.87|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38||||38|17.62|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38||||38|10.81|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|38||||38|10.81|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|38||||38|26.22|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38||||38|10.81|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|Self-pay|Self-pay|38||||38|13.3|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|38||||38|10.81|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38||||38|10.81|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38||||38|17.99|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|38||||38|12.87|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|38||||38|12.87|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38||||38|17.99|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38||||38|12.87|26.22|10.81
30182951|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOL 1ST 3 SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38||||38|25.74|26.22|10.81
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|AARP [1000]|AARP [100000]|263||||263|5.48|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|263||||263|3.96|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|AETNA [1015]|AETNA [101529]|263||||263|5.35|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|263||||263|3.29|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|263||||263|3.92|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|263||||263|3.92|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|BCBS [1155]|BCBS UTHCT [115568]|263||||263|123.61|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|263||||263|5.9|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|263||||263|131.5|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|263||||263|165.69|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|263||||263|3.29|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|263||||263|3.92|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|CIGNA [1260]|CIGNA GWH [126023]|263||||263|7.26|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|263||||263|181.47|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|263||||263|4.9|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|263||||263|3.92|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|263||||263|5.35|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|263||||263|3.29|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|263||||263|3.92|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|263||||263|5.35|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|263||||263|3.29|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|263||||263|3.29|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|263||||263|181.47|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|263||||263|3.29|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|Self-pay|Self-pay|263||||263|92.05|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|263||||263|3.29|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|263||||263|3.29|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|263||||263|5.48|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|263||||263|3.92|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|263||||263|3.92|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|263||||263|5.48|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|263||||263|3.92|181.47|3.29
30182952|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE TOLER ADDL SPECMN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|263||||263|7.84|181.47|3.29
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|AARP [1000]|AARP [100000]|49||||49|13.55|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49||||49|9.8|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|AETNA [1015]|AETNA [101529]|49||||49|13.27|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49||||49|8.15|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49||||49|9.7|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49||||49|9.7|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|BCBS [1155]|BCBS UTHCT [115568]|49||||49|23.03|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49||||49|14.6|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49||||49|24.5|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49||||49|30.87|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49||||49|8.15|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49||||49|9.7|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|CIGNA [1260]|CIGNA GWH [126023]|49||||49|11.33|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|49||||49|33.81|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|49||||49|12.13|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49||||49|9.7|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49||||49|13.27|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49||||49|8.15|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49||||49|9.7|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49||||49|13.27|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49||||49|8.15|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|49||||49|8.15|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|49||||49|33.81|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49||||49|8.15|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|Self-pay|Self-pay|49||||49|17.15|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|49||||49|8.15|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49||||49|8.15|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49||||49|13.55|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|49||||49|9.7|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|49||||49|9.7|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49||||49|13.55|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49||||49|9.7|33.81|8.15
30182955|EAP|0301 - LABORATORY-CHEMISTRY|HC G6PD ENZYME QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49||||49|19.4|33.81|8.15
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AARP [1000]|AARP [100000]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AETNA [1015]|AETNA [101529]|20||||20|4.49|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20|5.93|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BCBS UTHCT [115568]|20||||20|9.4|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|4|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|10|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|12.6|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20|5.93|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|CIGNA [1260]|CIGNA GWH [126023]|20||||20|4.54|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20||||20|4.1|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|4.49|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20|5.93|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|4.49|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20||||20|5.93|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20||||20|5.93|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20|5.93|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|Self-pay|Self-pay|20||||20|7|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20||||20|5.93|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20|5.93|13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20||13.8|4
30182962|EAP|0301 - LABORATORY-CHEMISTRY|HC GLUCOSE BLOOD TEST BY DEVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20||||20||13.8|4
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AARP [1000]|AARP [100000]|166||||166|10.06|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|166||||166|7.27|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AETNA [1015]|AETNA [101529]|166||||166|9.84|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|166||||166|6.05|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|166||||166|7.2|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|166||||166|7.2|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BCBS UTHCT [115568]|166||||166|78.02|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|166||||166|10.85|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|166||||166|83|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|166||||166|104.58|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|166||||166|6.05|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|166||||166|7.2|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|CIGNA [1260]|CIGNA GWH [126023]|166||||166|8.5|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|166||||166|114.54|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|166||||166|9|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|166||||166|7.2|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|166||||166|9.84|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|166||||166|6.05|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|166||||166|7.2|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|166||||166|9.84|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|166||||166|6.05|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|166||||166|6.05|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|166||||166|114.54|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|166||||166|6.05|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|Self-pay|Self-pay|166||||166|58.1|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|166||||166|6.05|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|166||||166|6.05|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|166||||166|10.06|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|166||||166|7.2|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|166||||166|7.2|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|166||||166|10.06|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|166||||166|7.2|114.54|6.05
30182977|EAP|0301 - LABORATORY-CHEMISTRY|HC GGT/GGTP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|166||||166|14.4|114.54|6.05
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|AARP [1000]|AARP [100000]|56||||56|21.06|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56||||56|16.93|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|AETNA [1015]|AETNA [101529]|56||||56|22.92|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56||||56|14.08|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56||||56|16.76|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|56||||56|16.76|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|BCBS [1155]|BCBS UTHCT [115568]|56||||56|26.32|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56||||56|22.7|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56||||56|28|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56||||56|35.28|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56||||56|14.08|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56||||56|16.76|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|CIGNA [1260]|CIGNA GWH [126023]|56||||56|17.57|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|56||||56|38.64|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|56||||56|20.95|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|56||||56|16.76|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56||||56|22.92|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56||||56|14.08|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56||||56|16.76|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56||||56|22.92|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|56||||56|14.08|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|56||||56|14.08|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|56||||56|38.64|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56||||56|14.08|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|Self-pay|Self-pay|56||||56|19.6|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|56||||56|14.08|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56||||56|14.08|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56||||56|21.06|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|56||||56|16.76|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|56||||56|16.76|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56||||56|21.06|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56||||56|16.76|38.64|14.08
30182985|EAP|0301 - LABORATORY-CHEMISTRY|HC GLYCATED PROTEIN-FRUCTOSAMINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|56||||56|33.52|38.64|14.08
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|AARP [1000]|AARP [100000]|165||||165|25.97|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|165||||165|18.77|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|AETNA [1015]|AETNA [101529]|165||||165|25.42|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|165||||165|15.61|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|165||||165|18.58|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|165||||165|18.58|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|BCBS [1155]|BCBS UTHCT [115568]|165||||165|77.55|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|165||||165|27.99|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|165||||165|82.5|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|165||||165|103.95|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|165||||165|15.61|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|165||||165|18.58|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|CIGNA [1260]|CIGNA GWH [126023]|165||||165|21.53|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|165||||165|113.85|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|165||||165|23.23|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|165||||165|18.58|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|165||||165|25.42|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|165||||165|15.61|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|165||||165|18.58|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|165||||165|25.42|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|165||||165|15.61|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|165||||165|15.61|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|165||||165|113.85|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|165||||165|15.61|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|Self-pay|Self-pay|165||||165|57.75|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|165||||165|15.61|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|165||||165|15.61|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|165||||165|25.97|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|165||||165|18.58|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|165||||165|18.58|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|165||||165|25.97|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|165||||165|18.58|113.85|15.61
30183001|EAP|0301 - LABORATORY-CHEMISTRY|HC FSH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|165||||165|37.16|113.85|15.61
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|AARP [1000]|AARP [100000]|217||||217|25.88|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217||||217|18.71|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|AETNA [1015]|AETNA [101529]|217||||217|25.34|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217||||217|15.56|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217||||217|18.52|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217||||217|18.52|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|BCBS [1155]|BCBS UTHCT [115568]|217||||217|101.99|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217||||217|27.89|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217||||217|108.5|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217||||217|136.71|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217||||217|15.56|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217||||217|18.52|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|CIGNA [1260]|CIGNA GWH [126023]|217||||217|21.53|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|217||||217|149.73|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|217||||217|23.15|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217||||217|18.52|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217||||217|25.34|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217||||217|15.56|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217||||217|18.52|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217||||217|25.34|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217||||217|15.56|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|217||||217|15.56|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|217||||217|149.73|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217||||217|15.56|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|Self-pay|Self-pay|217||||217|75.95|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|217||||217|15.56|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217||||217|15.56|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217||||217|25.88|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|217||||217|18.52|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|217||||217|18.52|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217||||217|25.88|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217||||217|18.52|149.73|15.56
30183002|EAP|0301 - LABORATORY-CHEMISTRY|HC LUTEINIZING HORMONE (LH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217||||217|37.04|149.73|15.56
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|AARP [1000]|AARP [100000]|171||||171|23.29|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|171||||171|16.84|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|AETNA [1015]|AETNA [101529]|171||||171|22.8|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|171||||171|14|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|171||||171|16.67|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|171||||171|16.67|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|BCBS [1155]|BCBS UTHCT [115568]|171||||171|80.37|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|171||||171|25.11|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|171||||171|85.5|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|171||||171|107.73|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|171||||171|14|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|171||||171|16.67|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|CIGNA [1260]|CIGNA GWH [126023]|171||||171|19.27|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|171||||171|117.99|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|171||||171|20.84|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|171||||171|16.67|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|171||||171|22.8|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|171||||171|14|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|171||||171|16.67|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|171||||171|22.8|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|171||||171|14|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|171||||171|14|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|171||||171|117.99|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|171||||171|14|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|Self-pay|Self-pay|171||||171|59.85|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|171||||171|14|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|171||||171|14|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|171||||171|23.29|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|171||||171|16.67|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|171||||171|16.67|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|171||||171|23.29|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|171||||171|16.67|117.99|14
30183003|EAP|0301 - LABORATORY-CHEMISTRY|HC GROWTH HORMONE (HGH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|171||||171|33.34|117.99|14
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AARP [1000]|AARP [100000]|198||||198|17.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|198||||198|12.71|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AETNA [1015]|AETNA [101529]|198||||198|17.21|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|198||||198|10.57|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|198||||198|12.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|198||||198|12.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BCBS UTHCT [115568]|198||||198|93.06|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|198||||198|18.95|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|198||||198|99|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|198||||198|124.74|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|198||||198|10.57|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|198||||198|12.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|CIGNA [1260]|CIGNA GWH [126023]|198||||198|14.74|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|198||||198|136.62|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|198||||198|15.73|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|198||||198|12.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|198||||198|17.21|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|198||||198|10.57|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|198||||198|12.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|198||||198|17.21|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|198||||198|10.57|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|198||||198|10.57|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|198||||198|136.62|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|198||||198|10.57|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|Self-pay|Self-pay|198||||198|69.3|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|198||||198|10.57|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|198||||198|10.57|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|198||||198|17.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|198||||198|12.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|198||||198|12.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|198||||198|17.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|198||||198|12.58|136.62|10.57
30183010|EAP|0301 - LABORATORY-CHEMISTRY|HC HAPTOGLOBIN QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|198||||198|25.16|136.62|10.57
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|AARP [1000]|AARP [100000]|328||||328|94.11|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|328||||328|68.03|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|AETNA [1015]|AETNA [101529]|328||||328|92.16|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|328||||328|56.58|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|328||||328|67.36|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|328||||328|67.36|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|BCBS [1155]|BCBS UTHCT [115568]|328||||328|154.16|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|328||||328|101.46|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|328||||328|164|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|328||||328|206.64|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|328||||328|56.58|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|328||||328|67.36|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|CIGNA [1260]|CIGNA GWH [126023]|328||||328|125.09|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|328||||328|226.32|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|328||||328|84.2|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|328||||328|67.36|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|328||||328|92.16|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|328||||328|56.58|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|328||||328|67.36|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|328||||328|92.16|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|328||||328|56.58|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|328||||328|56.58|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|328||||328|226.32|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|328||||328|56.58|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|Self-pay|Self-pay|328||||328|114.8|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|328||||328|56.58|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|328||||328|56.58|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|328||||328|94.11|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|328||||328|67.36|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|328||||328|67.36|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|328||||328|94.11|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|328||||328|67.36|226.32|56.58
30183013|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA BREATH TEST FOR HPYLORI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|328||||328|134.72|226.32|56.58
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|AARP [1000]|AARP [100000]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|AETNA [1015]|AETNA [101529]|86||||86|30.05|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|BCBS [1155]|BCBS UTHCT [115568]|86||||86|40.42|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|86||||86|33.09|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|86||||86|43|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|86||||86|54.18|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|CIGNA [1260]|CIGNA GWH [126023]|86||||86|25.49|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|86||||86|59.34|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|86||||86|27.45|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86||||86|30.05|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|86||||86|30.05|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|86||||86|59.34|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|Self-pay|Self-pay|86||||86|30.1|59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|86||||86||59.34|25.49
30183018|EAP|0301 - LABORATORY-CHEMISTRY|HC HEAVY METAL QN NES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|86||||86||59.34|25.49
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AARP [1000]|AARP [100000]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AETNA [1015]|AETNA [101529]|240||||240|17.62|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BCBS UTHCT [115568]|240||||240|112.8|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|240||||240|19.39|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|240||||240|120|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|240||||240|151.2|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|CIGNA [1260]|CIGNA GWH [126023]|240||||240|28.13|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|240||||240|165.6|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|240||||240|16.09|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|240||||240|17.62|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|240||||240|17.62|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|240||||240|165.6|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|Self-pay|Self-pay|240||||240|84|165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|240||||240||165.6|16.09
30183020|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN ELECTROPHORESIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|240||||240||165.6|16.09
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|AARP [1000]|AARP [100000]|104||||104|25.23|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104||||104|18.24|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|AETNA [1015]|AETNA [101529]|104||||104|24.7|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104||||104|15.17|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104||||104|18.06|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104||||104|18.06|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|BCBS [1155]|BCBS UTHCT [115568]|104||||104|48.88|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104||||104|27.19|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104||||104|52|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104||||104|65.52|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104||||104|15.17|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104||||104|18.06|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|CIGNA [1260]|CIGNA GWH [126023]|104||||104|20.96|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104||||104|71.76|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|104||||104|22.58|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104||||104|18.06|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104||||104|24.7|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104||||104|15.17|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104||||104|18.06|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104||||104|24.7|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104||||104|15.17|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|104||||104|15.17|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104||||104|71.76|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104||||104|15.17|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|Self-pay|Self-pay|104||||104|36.4|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|104||||104|15.17|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104||||104|15.17|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104||||104|25.23|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|104||||104|18.06|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|104||||104|18.06|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104||||104|25.23|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104||||104|18.06|71.76|15.17
30183021|EAP|0301 - LABORATORY-CHEMISTRY|HC HGB FRACT QUANT CHROMATOGRAPHY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104||||104|36.12|71.76|15.17
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AARP [1000]|AARP [100000]|163||||163|13.56|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163||||163|9.81|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AETNA [1015]|AETNA [101529]|163||||163|13.27|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163||||163|8.16|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163||||163|9.71|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163||||163|9.71|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BCBS UTHCT [115568]|163||||163|76.61|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163||||163|14.63|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163||||163|81.5|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163||||163|102.69|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163||||163|8.16|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163||||163|9.71|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|CIGNA [1260]|CIGNA GWH [126023]|163||||163|18.13|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163||||163|112.47|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|163||||163|12.14|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163||||163|9.71|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163||||163|13.27|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163||||163|8.16|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163||||163|9.71|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163||||163|13.27|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163||||163|8.16|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|163||||163|8.16|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163||||163|112.47|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163||||163|8.16|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|Self-pay|Self-pay|163||||163|57.05|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|163||||163|8.16|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163||||163|8.16|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163||||163|13.56|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|163||||163|9.71|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|163||||163|9.71|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163||||163|13.56|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163||||163|9.71|112.47|8.16
30183036|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN GLYCOSYLATED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163||||163|19.42|112.47|8.16
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|AARP [1000]|AARP [100000]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|AETNA [1015]|AETNA [101529]|142||||142|11.21|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|BCBS [1155]|BCBS UTHCT [115568]|142||||142|66.74|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|142||||142|11.04|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|142||||142|71|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|142||||142|89.46|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|CIGNA [1260]|CIGNA GWH [126023]|142||||142|8.5|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|142||||142|97.98|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|142||||142|10.25|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|142||||142|11.21|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|142||||142|11.21|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|142||||142|97.98|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|Self-pay|Self-pay|142||||142|49.7|97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|142||||142||97.98|8.5
30183050|EAP|0301 - LABORATORY-CHEMISTRY|HC METHEMOGLOBIN QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|142||||142||97.98|8.5
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|AARP [1000]|AARP [100000]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|AETNA [1015]|AETNA [101529]|20||||20|10.01|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|BCBS [1155]|BCBS UTHCT [115568]|20||||20|9.4|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|11.02|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|10|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|12.6|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|CIGNA [1260]|CIGNA GWH [126023]|20||||20|8.5|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20||||20|9.14|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|10.01|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|10.01|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|Self-pay|Self-pay|20||||20|7|13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20||13.8|7
30183051|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOGLOBIN PLASMA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20||||20||13.8|7
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|AARP [1000]|AARP [100000]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|AETNA [1015]|AETNA [101529]|13||||13|6.5|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|BCBS [1155]|BCBS UTHCT [115568]|13||||13|6.11|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13||||13|7.15|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13||||13|6.5|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13||||13|8.19|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|CIGNA [1260]|CIGNA GWH [126023]|13||||13|5.39|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|13||||13|8.97|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13||||13|5.94|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13||||13|6.5|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13||||13|6.5|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|13||||13|8.97|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|Self-pay|Self-pay|13||||13|4.55|8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13||||13||8.97|4.55
30183070|EAP|0301 - LABORATORY-CHEMISTRY|HC HEMOSIDERIN QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13||||13||8.97|4.55
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|AARP [1000]|AARP [100000]|65||||65|41.26|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65||||65|29.83|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|AETNA [1015]|AETNA [101529]|65||||65|40.39|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65||||65|24.81|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65||||65|29.53|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65||||65|29.53|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|BCBS [1155]|BCBS UTHCT [115568]|65||||65|30.55|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65||||65|44.48|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65||||65|32.5|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65||||65|40.95|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65||||65|24.81|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65||||65|29.53|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|CIGNA [1260]|CIGNA GWH [126023]|65||||65|34.27|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|65||||65|44.85|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65||||65|36.91|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65||||65|29.53|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65||||65|40.39|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65||||65|24.81|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65||||65|29.53|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65||||65|40.39|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65||||65|24.81|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|65||||65|24.81|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|65||||65|44.85|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65||||65|24.81|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|Self-pay|Self-pay|65||||65|22.75|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65||||65|24.81|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65||||65|24.81|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65||||65|41.26|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65||||65|29.53|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65||||65|29.53|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65||||65|41.26|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65||||65|29.53|59.06|22.75
30183088|EAP|0301 - LABORATORY-CHEMISTRY|HC HISTAMINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65||||65|59.06|59.06|22.75
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AARP [1000]|AARP [100000]|620||||620|23.57|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|620||||620|18.1|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AETNA [1015]|AETNA [101529]|620||||620|24.5|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|620||||620|15.05|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|620||||620|17.92|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|620||||620|17.92|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS [1155]|BCBS UTHCT [115568]|620||||620|291.4|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|620||||620|25.41|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|620||||620|310|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|620||||620|390.6|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|620||||620|15.05|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|620||||620|17.92|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|CIGNA [1260]|CIGNA GWH [126023]|620||||620|19.54|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|620||||620|427.8|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|620||||620|22.4|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|620||||620|17.92|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|620||||620|24.5|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|620||||620|15.05|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|620||||620|17.92|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|620||||620|24.5|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|620||||620|15.05|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|620||||620|15.05|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|620||||620|427.8|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|620||||620|15.05|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|Self-pay|Self-pay|620||||620|217|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|620||||620|15.05|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|620||||620|15.05|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|620||||620|23.57|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|620||||620|17.92|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|620||||620|17.92|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|620||||620|23.57|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|620||||620|17.92|427.8|15.05
30183090|EAP|0301 - LABORATORY-CHEMISTRY|HC HOMOCYSTEINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|620||||620|35.84|427.8|15.05
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|AARP [1000]|AARP [100000]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|AETNA [1015]|AETNA [101529]|60||||60|24.48|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|BCBS [1155]|BCBS UTHCT [115568]|60||||60|28.2|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60||||60|26.4|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60||||60|30|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60||||60|37.8|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|CIGNA [1260]|CIGNA GWH [126023]|60||||60|20.39|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|60||||60|41.4|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|60||||60|22.38|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60||||60|24.48|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60||||60|24.48|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|60||||60|41.4|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|Self-pay|Self-pay|60||||60|21|41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60||||60||41.4|20.39
30183491|EAP|0301 - LABORATORY-CHEMISTRY|HC 17-OH-CORTICOSTEROIDS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60||||60||41.4|20.39
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|AARP [1000]|AARP [100000]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|AETNA [1015]|AETNA [101529]|264||||264|17.64|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|BCBS [1155]|BCBS UTHCT [115568]|264||||264|124.08|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264||||264|19.42|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264||||264|132|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264||||264|166.32|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|CIGNA [1260]|CIGNA GWH [126023]|264||||264|15.02|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264||||264|182.16|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|264||||264|16.13|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264||||264|17.64|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264||||264|17.64|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264||||264|182.16|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|Self-pay|Self-pay|264||||264|92.4|182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264||||264||182.16|15.02
30183497|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYINDOLACETIC 5-(HIAA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264||||264||182.16|15.02
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|AARP [1000]|AARP [100000]|175||||175|37.95|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175||||175|27.44|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|AETNA [1015]|AETNA [101529]|175||||175|37.18|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175||||175|22.82|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175||||175|27.17|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175||||175|27.17|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|BCBS [1155]|BCBS UTHCT [115568]|175||||175|82.25|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175||||175|40.92|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175||||175|87.5|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175||||175|110.25|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175||||175|22.82|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175||||175|27.17|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|CIGNA [1260]|CIGNA GWH [126023]|175||||175|31.45|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|GROUP PENSION ADMIN [1450]|GPA [145000]|175||||175|120.75|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|175||||175|33.96|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175||||175|27.17|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175||||175|37.18|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175||||175|22.82|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175||||175|27.17|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175||||175|37.18|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175||||175|22.82|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|175||||175|22.82|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|PHCS [1780]|PHCS MULTIPLAN [178000]|175||||175|120.75|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175||||175|22.82|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|Self-pay|Self-pay|175||||175|61.25|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|175||||175|22.82|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175||||175|22.82|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175||||175|37.95|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|175||||175|27.17|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|175||||175|27.17|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175||||175|37.95|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175||||175|27.17|120.75|22.82
30183498|EAP|0301 - LABORATORY-CHEMISTRY|HC HYDROXYPROGESTERONE 17-D|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175||||175|54.34|120.75|22.82
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AARP [1000]|AARP [100000]|266||||266|16.12|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|266||||266|11.65|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AETNA [1015]|AETNA [101529]|266||||266|15.77|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|266||||266|9.69|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|266||||266|11.53|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|266||||266|11.53|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BCBS UTHCT [115568]|266||||266|125.02|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|266||||266|17.37|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|266||||266|133|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|266||||266|167.58|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|266||||266|9.69|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|266||||266|11.53|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|CIGNA [1260]|CIGNA GWH [126023]|266||||266|13.32|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|266||||266|183.54|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|266||||266|14.41|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|266||||266|11.53|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|266||||266|15.77|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|266||||266|9.69|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|266||||266|11.53|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|266||||266|15.77|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|266||||266|9.69|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|266||||266|9.69|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|266||||266|183.54|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|266||||266|9.69|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|Self-pay|Self-pay|266||||266|93.1|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|266||||266|9.69|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|266||||266|9.69|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|266||||266|16.12|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|266||||266|11.53|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|266||||266|11.53|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|266||||266|16.12|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|266||||266|11.53|183.54|9.69
30183516|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO QL SQN MULTIPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|266||||266|23.06|183.54|9.69
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AARP [1000]|AARP [100000]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AETNA [1015]|AETNA [101529]|29||||29|25.18|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BCBS UTHCT [115568]|29||||29|13.63|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29||||29|22.45|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29||||29|14.5|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29||||29|18.27|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|CIGNA [1260]|CIGNA GWH [126023]|29||||29|15.58|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|29||||29|20.01|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29||||29|23|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29||||29|25.18|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29||||29|25.18|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|29||||29|20.01|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|Self-pay|Self-pay|29||||29|10.15|25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29||||29||25.18|10.15
30183519|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNO RIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29||||29||25.18|10.15
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AARP [1000]|AARP [100000]|395||||395|18.09|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|395||||395|17.44|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AETNA [1015]|AETNA [101529]|395||||395|23.62|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|395||||395|14.51|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|395||||395|17.27|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|395||||395|17.27|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BCBS UTHCT [115568]|395||||395|185.65|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|395||||395|21.07|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|395||||395|197.5|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|395||||395|248.85|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|395||||395|14.51|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|395||||395|17.27|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|CIGNA [1260]|CIGNA GWH [126023]|395||||395|15.02|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|395||||395|272.55|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|395||||395|21.59|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|395||||395|17.27|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|395||||395|23.62|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|395||||395|14.51|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|395||||395|17.27|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|395||||395|23.62|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|395||||395|14.51|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|395||||395|14.51|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|395||||395|272.55|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|395||||395|14.51|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|Self-pay|Self-pay|395||||395|138.25|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|395||||395|14.51|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|395||||395|14.51|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|395||||395|18.09|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|395||||395|17.27|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|395||||395|17.27|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|395||||395|18.09|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|395||||395|17.27|272.55|14.51
30183520|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY OTHER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|395||||395|34.54|272.55|14.51
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AARP [1000]|AARP [100000]|191||||191|15.98|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|191||||191|11.54|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AETNA [1015]|AETNA [101529]|191||||191|15.65|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|191||||191|9.6|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|191||||191|11.43|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|191||||191|11.43|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|191||||191|89.77|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|191||||191|17.21|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|191||||191|95.5|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|191||||191|120.33|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|191||||191|9.6|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|191||||191|11.43|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|191||||191|13.32|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|191||||191|131.79|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|191||||191|14.29|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|191||||191|11.43|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|191||||191|15.65|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|191||||191|9.6|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|191||||191|11.43|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|191||||191|15.65|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|191||||191|9.6|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|191||||191|9.6|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|191||||191|131.79|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|191||||191|9.6|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|Self-pay|Self-pay|191||||191|66.85|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|191||||191|9.6|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|191||||191|9.6|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|191||||191|15.98|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|191||||191|11.43|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|191||||191|11.43|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|191||||191|15.98|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|191||||191|11.43|131.79|9.6
30183525|EAP|0301 - LABORATORY-CHEMISTRY|HC INSULIN TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|191||||191|22.86|131.79|9.6
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AARP [1000]|AARP [100000]|521||||521|9.05|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|521||||521|6.53|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AETNA [1015]|AETNA [101529]|521||||521|8.86|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|521||||521|5.43|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|521||||521|6.47|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|521||||521|6.47|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BCBS UTHCT [115568]|521||||521|244.87|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|521||||521|9.75|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|521||||521|260.5|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|521||||521|328.23|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|521||||521|5.43|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|521||||521|6.47|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|CIGNA [1260]|CIGNA GWH [126023]|521||||521|7.64|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|521||||521|359.49|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|521||||521|8.09|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|521||||521|6.47|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|521||||521|8.86|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|521||||521|5.43|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|521||||521|6.47|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|521||||521|8.86|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|521||||521|5.43|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|521||||521|5.43|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|521||||521|359.49|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|521||||521|5.43|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|Self-pay|Self-pay|521||||521|182.35|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|521||||521|5.43|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|521||||521|5.43|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|521||||521|9.05|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|521||||521|6.47|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|521||||521|6.47|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|521||||521|9.05|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|521||||521|6.47|359.49|5.43
30183540|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|521||||521|12.94|359.49|5.43
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AARP [1000]|AARP [100000]|146||||146|12.21|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146|8.83|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AETNA [1015]|AETNA [101529]|146||||146|11.95|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146|7.34|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146|8.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146||||146|8.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BCBS UTHCT [115568]|146||||146|68.62|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|13.16|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|91.98|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146|7.34|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146|8.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|CIGNA [1260]|CIGNA GWH [126023]|146||||146|10.2|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|146||||146|10.93|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146||||146|8.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|11.95|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146|7.34|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146|8.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|11.95|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146||||146|7.34|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|146||||146|7.34|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146|7.34|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|Self-pay|Self-pay|146||||146|51.1|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|146||||146|7.34|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146|7.34|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146|12.21|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|146||||146|8.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|146||||146|8.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146|12.21|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146|8.74|100.74|7.34
30183550|EAP|0301 - LABORATORY-CHEMISTRY|HC IRON BINDING CAPACITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146||||146|17.48|100.74|7.34
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|AARP [1000]|AARP [100000]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|AETNA [1015]|AETNA [101529]|90||||90|17.52|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|90||||90|42.3|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90||||90|19.28|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90||||90|45|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90||||90|56.7|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|90||||90|15.02|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|90||||90|62.1|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|90||||90|16|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90||||90|17.52|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90||||90|17.52|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|90||||90|62.1|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|Self-pay|Self-pay|90||||90|31.5|62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90||||90||62.1|15.02
30183586|EAP|0301 - LABORATORY-CHEMISTRY|HC KETOSTEROIDS (17-KS) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90||||90||62.1|15.02
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AARP [1000]|AARP [100000]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AETNA [1015]|AETNA [101529]|175||||175|15.82|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BCBS UTHCT [115568]|175||||175|82.25|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175||||175|16.09|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175||||175|87.5|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175||||175|110.25|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|CIGNA [1260]|CIGNA GWH [126023]|175||||175|12.47|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|175||||175|120.75|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|175||||175|14.46|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175||||175|15.82|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175||||175|15.82|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|175||||175|120.75|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|Self-pay|Self-pay|175||||175|61.25|120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175||||175||120.75|12.47
30183605|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE/LACTIC ACID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175||||175||120.75|12.47
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AARP [1000]|AARP [100000]|158||||158|8.44|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158||||158|6.1|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AETNA [1015]|AETNA [101529]|158||||158|8.26|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158||||158|5.07|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158||||158|6.04|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158||||158|6.04|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BCBS UTHCT [115568]|158||||158|74.26|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158||||158|9.09|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158||||158|79|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158||||158|99.54|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158||||158|5.07|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158||||158|6.04|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|CIGNA [1260]|CIGNA GWH [126023]|158||||158|7.08|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|158||||158|109.02|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|158||||158|7.55|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158||||158|6.04|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158||||158|8.26|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158||||158|5.07|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158||||158|6.04|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158||||158|8.26|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158||||158|5.07|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|158||||158|5.07|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|158||||158|109.02|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158||||158|5.07|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|Self-pay|Self-pay|158||||158|55.3|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|158||||158|5.07|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158||||158|5.07|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158||||158|8.44|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|158||||158|6.04|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|158||||158|6.04|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158||||158|8.44|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158||||158|6.04|109.02|5.07
30183615|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTATE DEHYDROGENASE (LDH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158||||158|12.08|109.02|5.07
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|AARP [1000]|AARP [100000]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|AETNA [1015]|AETNA [101529]|36||||36|17.5|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|BCBS [1155]|BCBS UTHCT [115568]|36||||36|16.92|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|19.28|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|18|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|22.68|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|CIGNA [1260]|CIGNA GWH [126023]|36||||36|14.74|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|36||||36|15.99|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|17.5|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|17.5|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|Self-pay|Self-pay|36||||36|12.6|24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36||24.84|12.6
30183625|EAP|0301 - LABORATORY-CHEMISTRY|HC LDH ISOENZYME|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36||||36||24.84|12.6
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|AARP [1000]|AARP [100000]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|AETNA [1015]|AETNA [101529]|51||||51|26.95|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|BCBS [1155]|BCBS UTHCT [115568]|51||||51|23.97|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51||||51|29.57|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51||||51|25.5|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51||||51|32.13|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|CIGNA [1260]|CIGNA GWH [126023]|51||||51|22.67|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|51||||51|35.19|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|51||||51|24.63|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51||||51|26.95|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51||||51|26.95|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|51||||51|35.19|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|Self-pay|Self-pay|51||||51|17.85|35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51||||51||35.19|17.85
30183630|EAP|0301 - LABORATORY-CHEMISTRY|HC LACTOFERRIN FECAL QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51||||51||35.19|17.85
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|AARP [1000]|AARP [100000]|184||||184|16.91|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184||||184|12.23|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|AETNA [1015]|AETNA [101529]|184||||184|16.56|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184||||184|10.17|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184||||184|12.11|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184||||184|12.11|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|BCBS [1155]|BCBS UTHCT [115568]|184||||184|86.48|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184||||184|18.24|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184||||184|92|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184||||184|115.92|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184||||184|10.17|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184||||184|12.11|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|CIGNA [1260]|CIGNA GWH [126023]|184||||184|14.17|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|184||||184|126.96|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|184||||184|15.14|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184||||184|12.11|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184||||184|16.56|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184||||184|10.17|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184||||184|12.11|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184||||184|16.56|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184||||184|10.17|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|184||||184|10.17|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|184||||184|126.96|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184||||184|10.17|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|Self-pay|Self-pay|184||||184|64.4|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|184||||184|10.17|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184||||184|10.17|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184||||184|16.91|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|184||||184|12.11|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|184||||184|12.11|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184||||184|16.91|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184||||184|12.11|126.96|10.17
30183655|EAP|0301 - LABORATORY-CHEMISTRY|HC LEAD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184||||184|24.22|126.96|10.17
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AARP [1000]|AARP [100000]|161||||161|9.62|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161||||161|6.96|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AETNA [1015]|AETNA [101529]|161||||161|9.43|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161||||161|5.79|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161||||161|6.89|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161||||161|6.89|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BCBS UTHCT [115568]|161||||161|75.67|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161||||161|10.38|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161||||161|80.5|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161||||161|101.43|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161||||161|5.79|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161||||161|6.89|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|CIGNA [1260]|CIGNA GWH [126023]|161||||161|7.93|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|161||||161|111.09|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|161||||161|8.61|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161||||161|6.89|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161||||161|9.43|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161||||161|5.79|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161||||161|6.89|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161||||161|9.43|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161||||161|5.79|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|161||||161|5.79|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|161||||161|111.09|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161||||161|5.79|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|Self-pay|Self-pay|161||||161|56.35|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|161||||161|5.79|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161||||161|5.79|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161||||161|9.62|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|161||||161|6.89|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|161||||161|6.89|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161||||161|9.62|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161||||161|6.89|111.09|5.79
30183690|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161||||161|13.78|111.09|5.79
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|AARP [1000]|AARP [100000]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|AETNA [1015]|AETNA [101529]|142||||142|19.58|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|BCBS [1155]|BCBS UTHCT [115568]|142||||142|66.74|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|142||||142|19.5|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|142||||142|71|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|142||||142|89.46|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|CIGNA [1260]|CIGNA GWH [126023]|142||||142|15.02|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|142||||142|97.98|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|142||||142|17.9|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|142||||142|19.58|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|142||||142|19.58|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|142||||142|97.98|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|Self-pay|Self-pay|142||||142|49.7|97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|142||||142||97.98|15.02
30183695|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN(A)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|142||||142||97.98|15.02
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|AARP [1000]|AARP [100000]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|AETNA [1015]|AETNA [101529]|66||||66|15.41|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|BCBS [1155]|BCBS UTHCT [115568]|66||||66|31.02|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|16.96|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|41.58|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|CIGNA [1260]|CIGNA GWH [126023]|66||||66|13.03|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66||||66|14.08|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|15.41|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|15.41|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|Self-pay|Self-pay|66||||66|23.1|45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|13.03
30183700|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLOOD ELECTROPHORECTIC SEP&QUAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|13.03
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|AARP [1000]|AARP [100000]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|AETNA [1015]|AETNA [101529]|64||||64|46.78|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|BCBS [1155]|BCBS UTHCT [115568]|64||||64|30.08|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64||||64|47.52|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64||||64|32|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64||||64|40.32|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|CIGNA [1260]|CIGNA GWH [126023]|64||||64|36.55|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|64||||64|44.16|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|64||||64|42.74|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64||||64|46.78|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64||||64|46.78|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|64||||64|44.16|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|Self-pay|Self-pay|64||||64|22.4|47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64||||64||47.52|22.4
30183704|EAP|0301 - LABORATORY-CHEMISTRY|HC LIPOPROTEIN BLD QUAN PARTICLE NUMBER(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64||||64||47.52|22.4
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|AARP [1000]|AARP [100000]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|AETNA [1015]|AETNA [101529]|95||||95|11.21|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|BCBS [1155]|BCBS UTHCT [115568]|95||||95|44.65|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|95||||95|12.35|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|95||||95|47.5|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|95||||95|59.85|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|CIGNA [1260]|CIGNA GWH [126023]|95||||95|9.64|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|95||||95|65.55|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|95||||95|10.24|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95||||95|11.21|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95||||95|11.21|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|95||||95|65.55|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|Self-pay|Self-pay|95||||95|33.25|65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95||||95||65.55|9.64
30183718|EAP|0301 - LABORATORY-CHEMISTRY|HC HDL CHOLESTEROL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|95||||95||65.55|9.64
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|AARP [1000]|AARP [100000]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|AETNA [1015]|AETNA [101529]|20||||20|14.38|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|BCBS [1155]|BCBS UTHCT [115568]|20||||20|9.4|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|14.37|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|10|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|12.6|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|CIGNA [1260]|CIGNA GWH [126023]|20||||20|11.04|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20||||20|13.13|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|14.38|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|14.38|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|Self-pay|Self-pay|20||||20|7|14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20||14.38|7
30183721|EAP|0301 - LABORATORY-CHEMISTRY|HC LDL CHOLESTEROL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20||||20||14.38|7
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AARP [1000]|AARP [100000]|129||||129|9.36|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129||||129|6.77|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AETNA [1015]|AETNA [101529]|129||||129|9.17|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129||||129|5.63|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129||||129|6.7|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129||||129|6.7|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BCBS UTHCT [115568]|129||||129|60.63|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129||||129|10.09|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129||||129|64.5|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129||||129|81.27|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129||||129|5.63|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129||||129|6.7|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|CIGNA [1260]|CIGNA GWH [126023]|129||||129|7.64|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|129||||129|89.01|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|129||||129|8.38|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129||||129|6.7|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129||||129|9.17|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129||||129|5.63|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129||||129|6.7|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129||||129|9.17|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129||||129|5.63|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|129||||129|5.63|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|129||||129|89.01|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129||||129|5.63|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|Self-pay|Self-pay|129||||129|45.15|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|129||||129|5.63|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129||||129|5.63|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129||||129|9.36|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|129||||129|6.7|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|129||||129|6.7|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129||||129|9.36|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129||||129|6.7|89.01|5.63
30183735|EAP|0301 - LABORATORY-CHEMISTRY|HC MAGNESIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129||||129|13.4|89.01|5.63
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|AARP [1000]|AARP [100000]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|AETNA [1015]|AETNA [101529]|50||||50|36.46|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|BCBS [1155]|BCBS UTHCT [115568]|50||||50|23.5|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50||||50|37.05|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50||||50|25|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50||||50|31.5|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|CIGNA [1260]|CIGNA GWH [126023]|50||||50|28.61|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|50||||50|34.5|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50||||50|33.31|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50||||50|36.46|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50||||50|36.46|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|50||||50|34.5|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|Self-pay|Self-pay|50||||50|17.5|37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50||||50||37.05|17.5
30183785|EAP|0301 - LABORATORY-CHEMISTRY|HC MANGANESE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50||||50||37.05|17.5
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|AARP [1000]|AARP [100000]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|AETNA [1015]|AETNA [101529]|696||||696|32.98|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|BCBS [1155]|BCBS UTHCT [115568]|696||||696|327.12|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|696||||696|29.41|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|696||||696|348|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|696||||696|438.48|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|CIGNA [1260]|CIGNA GWH [126023]|696||||696|20.96|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|696||||696|480.24|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|696||||696|30.14|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|696||||696|32.98|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|696||||696|32.98|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|696||||696|480.24|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|Self-pay|Self-pay|696||||696|243.6|480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|696||||696||480.24|20.96
30183789|EAP|0301 - LABORATORY-CHEMISTRY|HC MASS SPECTROMETRY QUAL/QUAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|696||||696||480.24|20.96
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|AARP [1000]|AARP [100000]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|AETNA [1015]|AETNA [101529]|266||||266|22.25|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|BCBS [1155]|BCBS UTHCT [115568]|266||||266|125.02|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|266||||266|24.49|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|266||||266|133|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|266||||266|167.58|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|CIGNA [1260]|CIGNA GWH [126023]|266||||266|18.98|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|266||||266|183.54|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|266||||266|20.33|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|266||||266|22.25|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|266||||266|22.25|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|266||||266|183.54|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|Self-pay|Self-pay|266||||266|93.1|183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|266||||266||183.54|18.98
30183825|EAP|0301 - LABORATORY-CHEMISTRY|HC MERCURY QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|266||||266||183.54|18.98
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AARP [1000]|AARP [100000]|671||||671|23.67|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|671||||671|17.11|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AETNA [1015]|AETNA [101529]|671||||671|23.18|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|671||||671|14.23|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|671||||671|16.94|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|671||||671|16.94|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS [1155]|BCBS UTHCT [115568]|671||||671|315.37|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|671||||671|25.52|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|671||||671|335.5|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|671||||671|422.73|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|671||||671|14.23|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|671||||671|16.94|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|CIGNA [1260]|CIGNA GWH [126023]|671||||671|19.54|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|671||||671|462.99|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|671||||671|21.18|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|671||||671|16.94|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|671||||671|23.18|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|671||||671|14.23|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|671||||671|16.94|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|671||||671|23.18|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|671||||671|14.23|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|671||||671|14.23|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|671||||671|462.99|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|671||||671|14.23|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|Self-pay|Self-pay|671||||671|234.85|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|671||||671|14.23|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|671||||671|14.23|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|671||||671|23.67|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|671||||671|16.94|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|671||||671|16.94|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|671||||671|23.67|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|671||||671|16.94|462.99|14.23
30183835|EAP|0301 - LABORATORY-CHEMISTRY|HC METANEPHRINES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|671||||671|33.88|462.99|14.23
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|AARP [1000]|AARP [100000]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|AETNA [1015]|AETNA [101529]|509||||509|23.52|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|BCBS [1155]|BCBS UTHCT [115568]|509||||509|239.23|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|509||||509|25.91|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|509||||509|254.5|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|509||||509|320.67|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|CIGNA [1260]|CIGNA GWH [126023]|509||||509|20.11|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|509||||509|351.21|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|509||||509|21.5|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|509||||509|23.52|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|509||||509|23.52|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|509||||509|351.21|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|Self-pay|Self-pay|509||||509|178.15|351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|509||||509||351.21|20.11
30183873|EAP|0301 - LABORATORY-CHEMISTRY|HC MYELIN BASIC PROTEIN CSF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|509||||509||351.21|20.11
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AARP [1000]|AARP [100000]|221||||221|18.04|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|221||||221|13.05|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AETNA [1015]|AETNA [101529]|221||||221|17.66|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|221||||221|10.85|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|221||||221|12.92|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|221||||221|12.92|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BCBS UTHCT [115568]|221||||221|103.87|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|221||||221|19.46|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|221||||221|110.5|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|221||||221|139.23|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|221||||221|10.85|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|221||||221|12.92|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|CIGNA [1260]|CIGNA GWH [126023]|221||||221|15.02|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|221||||221|152.49|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|221||||221|16.15|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|221||||221|12.92|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|221||||221|17.66|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|221||||221|10.85|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|221||||221|12.92|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|221||||221|17.66|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|221||||221|10.85|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|221||||221|10.85|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|221||||221|152.49|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|221||||221|10.85|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|Self-pay|Self-pay|221||||221|77.35|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|221||||221|10.85|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|221||||221|10.85|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|221||||221|18.04|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|221||||221|12.92|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|221||||221|12.92|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|221||||221|18.04|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|221||||221|12.92|152.49|10.85
30183874|EAP|0301 - LABORATORY-CHEMISTRY|HC MYOGLOBIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|221||||221|25.84|152.49|10.85
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AARP [1000]|AARP [100000]|351||||351|47.43|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|351||||351|39.65|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AETNA [1015]|AETNA [101529]|351||||351|53.71|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|351||||351|32.98|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|351||||351|39.26|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|351||||351|39.26|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BCBS UTHCT [115568]|351||||351|164.97|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|351||||351|51.12|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|351||||351|175.5|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|351||||351|221.13|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|351||||351|32.98|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|351||||351|39.26|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|CIGNA [1260]|CIGNA GWH [126023]|351||||351|39.37|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|351||||351|242.19|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|351||||351|49.08|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|351||||351|39.26|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|351||||351|53.71|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|351||||351|32.98|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|351||||351|39.26|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|351||||351|53.71|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|351||||351|32.98|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|351||||351|32.98|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|351||||351|242.19|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|351||||351|32.98|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|Self-pay|Self-pay|351||||351|122.85|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|351||||351|32.98|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|351||||351|32.98|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|351||||351|47.43|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|351||||351|39.26|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|351||||351|39.26|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|351||||351|47.43|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|351||||351|39.26|242.19|32.98
30183880|EAP|0301 - LABORATORY-CHEMISTRY|HC IMMUNOASSAY BNP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|351||||351|78.52|242.19|32.98
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AARP [1000]|AARP [100000]|117||||117|19|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|117||||117|13.74|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AETNA [1015]|AETNA [101529]|117||||117|18.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|117||||117|11.42|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|117||||117|13.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|117||||117|13.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BCBS UTHCT [115568]|117||||117|54.99|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|117||||117|20.48|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|117||||117|58.5|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|117||||117|73.71|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|117||||117|11.42|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|117||||117|13.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|CIGNA [1260]|CIGNA GWH [126023]|117||||117|15.86|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|117||||117|80.73|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|117||||117|17|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|117||||117|13.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|117||||117|18.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|117||||117|11.42|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|117||||117|13.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|117||||117|18.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|117||||117|11.42|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|117||||117|11.42|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|117||||117|80.73|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|117||||117|11.42|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|Self-pay|Self-pay|117||||117|40.95|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|117||||117|11.42|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|117||||117|11.42|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|117||||117|19|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|117||||117|13.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|117||||117|13.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|117||||117|19|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|117||||117|13.6|80.73|11.42
30183883|EAP|0301 - LABORATORY-CHEMISTRY|HC NEPHELOMETRY EA ANALYTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|117||||117|27.2|80.73|11.42
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|AARP [1000]|AARP [100000]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|AETNA [1015]|AETNA [101529]|200||||200|15.26|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|BCBS [1155]|BCBS UTHCT [115568]|200||||200|94|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|200||||200|16.8|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|200||||200|100|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|200||||200|126|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|CIGNA [1260]|CIGNA GWH [126023]|200||||200|13.03|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|GROUP PENSION ADMIN [1450]|GPA [145000]|200||||200|138|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|200||||200|13.94|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|200||||200|15.26|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|200||||200|15.26|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|PHCS [1780]|PHCS MULTIPLAN [178000]|200||||200|138|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|Self-pay|Self-pay|200||||200|70|138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|200||||200||138|13.03
30183915|EAP|0301 - LABORATORY-CHEMISTRY|HC NUCLEOTIDASE 5|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|200||||200||138|13.03
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|AARP [1000]|AARP [100000]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|AETNA [1015]|AETNA [101529]|304||||304|37.46|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|BCBS [1155]|BCBS UTHCT [115568]|304||||304|142.88|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|304||||304|33.42|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|304||||304|152|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|304||||304|191.52|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|CIGNA [1260]|CIGNA GWH [126023]|304||||304|23.23|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|304||||304|209.76|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|304||||304|34.24|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|304||||304|37.46|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|304||||304|37.46|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|304||||304|209.76|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|Self-pay|Self-pay|304||||304|106.4|209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|304||||304||209.76|23.23
30183916|EAP|0301 - LABORATORY-CHEMISTRY|HC OLIGOCLONAL BANDS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|304||||304||209.76|23.23
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|AARP [1000]|AARP [100000]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|AETNA [1015]|AETNA [101529]|386||||386|32.28|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|BCBS [1155]|BCBS UTHCT [115568]|386||||386|181.42|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386||||386|28.79|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386||||386|193|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386||||386|243.18|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|CIGNA [1260]|CIGNA GWH [126023]|386||||386|19.27|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386||||386|266.34|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|386||||386|29.5|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386||||386|32.28|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386||||386|32.28|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386||||386|266.34|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|Self-pay|Self-pay|386||||386|135.1|266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386||||386||266.34|19.27
30183918|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACIDS QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386||||386||266.34|19.27
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AARP [1000]|AARP [100000]|340||||340|23|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|340||||340|21.42|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AETNA [1015]|AETNA [101529]|340||||340|29.02|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|340||||340|17.82|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|340||||340|21.21|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|340||||340|21.21|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BCBS UTHCT [115568]|340||||340|159.8|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|340||||340|25.88|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|340||||340|170|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|340||||340|214.2|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|340||||340|17.82|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|340||||340|21.21|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|CIGNA [1260]|CIGNA GWH [126023]|340||||340|19.27|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|340||||340|234.6|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|340||||340|26.51|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|340||||340|21.21|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|340||||340|29.02|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|340||||340|17.82|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|340||||340|21.21|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|340||||340|29.02|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|340||||340|17.82|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|340||||340|17.82|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|340||||340|234.6|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|340||||340|17.82|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|Self-pay|Self-pay|340||||340|119|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|340||||340|17.82|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|340||||340|17.82|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|340||||340|23|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|340||||340|21.21|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|340||||340|21.21|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|340||||340|23|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|340||||340|21.21|234.6|17.82
30183921|EAP|0301 - LABORATORY-CHEMISTRY|HC ORGANIC ACID SINGLE QUANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|340||||340|42.42|234.6|17.82
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AARP [1000]|AARP [100000]|160||||160|9.24|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|160||||160|6.68|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AETNA [1015]|AETNA [101529]|160||||160|9.05|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|160||||160|5.55|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|160||||160|6.61|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|160||||160|6.61|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BCBS UTHCT [115568]|160||||160|75.2|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|160||||160|9.96|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|160||||160|80|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|160||||160|100.8|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|160||||160|5.55|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|160||||160|6.61|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|CIGNA [1260]|CIGNA GWH [126023]|160||||160|7.64|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|160||||160|110.4|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|160||||160|8.26|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|160||||160|6.61|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|160||||160|9.05|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|160||||160|5.55|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|160||||160|6.61|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|160||||160|9.05|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|160||||160|5.55|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|160||||160|5.55|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|160||||160|110.4|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|160||||160|5.55|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|Self-pay|Self-pay|160||||160|56|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|160||||160|5.55|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|160||||160|5.55|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|160||||160|9.24|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|160||||160|6.61|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|160||||160|6.61|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|160||||160|9.24|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|160||||160|6.61|110.4|5.55
30183930|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|160||||160|13.22|110.4|5.55
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AARP [1000]|AARP [100000]|144||||144|9.52|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|144||||144|6.89|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AETNA [1015]|AETNA [101529]|144||||144|9.34|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|144||||144|5.73|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|144||||144|6.82|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|144||||144|6.82|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BCBS UTHCT [115568]|144||||144|67.68|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|144||||144|10.27|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|144||||144|72|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|144||||144|90.72|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|144||||144|5.73|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|144||||144|6.82|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|CIGNA [1260]|CIGNA GWH [126023]|144||||144|7.93|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|144||||144|99.36|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|144||||144|8.53|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|144||||144|6.82|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|144||||144|9.34|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|144||||144|5.73|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|144||||144|6.82|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|144||||144|9.34|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|144||||144|5.73|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|144||||144|5.73|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|144||||144|99.36|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|144||||144|5.73|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|Self-pay|Self-pay|144||||144|50.4|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|144||||144|5.73|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|144||||144|5.73|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|144||||144|9.52|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|144||||144|6.82|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|144||||144|6.82|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|144||||144|9.52|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|144||||144|6.82|99.36|5.73
30183935|EAP|0301 - LABORATORY-CHEMISTRY|HC OSMOLALITY URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|144||||144|13.64|99.36|5.73
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|AARP [1000]|AARP [100000]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|AETNA [1015]|AETNA [101529]|122||||122|40.82|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|BCBS [1155]|BCBS UTHCT [115568]|122||||122|57.34|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122||||122|44.96|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122||||122|61|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122||||122|76.86|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|CIGNA [1260]|CIGNA GWH [126023]|122||||122|34.56|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|122||||122|84.18|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|122||||122|37.31|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122||||122|40.82|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122||||122|40.82|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|122||||122|84.18|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|Self-pay|Self-pay|122||||122|42.7|84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122||||122||84.18|34.56
30183937|EAP|0301 - LABORATORY-CHEMISTRY|HC OSTEOCALCIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122||||122||84.18|34.56
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|AARP [1000]|AARP [100000]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|AETNA [1015]|AETNA [101529]|183||||183|19.78|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|BCBS [1155]|BCBS UTHCT [115568]|183||||183|86.01|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|183||||183|19.39|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|183||||183|91.5|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|183||||183|115.29|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|CIGNA [1260]|CIGNA GWH [126023]|183||||183|15.02|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|183||||183|126.27|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|183||||183|18.06|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|183||||183|19.78|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|183||||183|19.78|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|183||||183|126.27|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|Self-pay|Self-pay|183||||183|64.05|126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|183||||183||126.27|15.02
30183945|EAP|0301 - LABORATORY-CHEMISTRY|HC OXALATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|183||||183||126.27|15.02
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|AARP [1000]|AARP [100000]|150||||150|94.04|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|150||||150|65.05|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|AETNA [1015]|AETNA [101529]|150||||150|88.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|150||||150|54.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|150||||150|64.41|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|150||||150|64.41|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|BCBS [1155]|BCBS UTHCT [115568]|150||||150|70.5|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|150||||150|97.01|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|150||||150|75|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|150||||150|94.5|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|150||||150|54.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|150||||150|64.41|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|CIGNA [1260]|CIGNA GWH [126023]|150||||150|82.5|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|150||||150|103.5|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|150||||150|80.51|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|150||||150|64.41|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|150||||150|88.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|150||||150|54.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|150||||150|64.41|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|150||||150|88.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|150||||150|54.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|150||||150|54.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|150||||150|103.5|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|150||||150|54.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|Self-pay|Self-pay|150||||150|52.5|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|150||||150|54.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|150||||150|54.1|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|150||||150|94.04|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|150||||150|64.41|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|150||||150|64.41|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|150||||150|94.04|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|150||||150|64.41|128.82|52.5
30183951|EAP|0301 - LABORATORY-CHEMISTRY|HC DCPDESGAMMACARBOXY PROTHROMB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|150||||150|128.82|128.82|52.5
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AARP [1000]|AARP [100000]|444||||444|57.67|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|444||||444|41.69|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AETNA [1015]|AETNA [101529]|444||||444|56.47|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|444||||444|34.68|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|444||||444|41.28|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|444||||444|41.28|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BCBS UTHCT [115568]|444||||444|208.68|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|444||||444|62.17|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|444||||444|222|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|444||||444|279.72|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|444||||444|34.68|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|444||||444|41.28|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|CIGNA [1260]|CIGNA GWH [126023]|444||||444|47.88|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|444||||444|306.36|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|444||||444|51.6|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|444||||444|41.28|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|444||||444|56.47|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|444||||444|34.68|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|444||||444|41.28|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|444||||444|56.47|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|444||||444|34.68|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|444||||444|34.68|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|444||||444|306.36|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|444||||444|34.68|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|Self-pay|Self-pay|444||||444|155.4|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|444||||444|34.68|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|444||||444|34.68|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|444||||444|57.67|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|444||||444|41.28|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|444||||444|41.28|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|444||||444|57.67|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|444||||444|41.28|306.36|34.68
30183970|EAP|0301 - LABORATORY-CHEMISTRY|HC PARATHORMONE (PTH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|444||||444|82.56|306.36|34.68
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AARP [1000]|AARP [100000]|76||||76|5|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76||||76|3.62|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AETNA [1015]|AETNA [101529]|76||||76|4.9|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76||||76|3.01|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76||||76|3.58|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76||||76|3.58|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS [1155]|BCBS UTHCT [115568]|76||||76|35.72|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76||||76|5.39|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76||||76|38|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76||||76|47.88|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76||||76|3.01|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76||||76|3.58|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|CIGNA [1260]|CIGNA GWH [126023]|76||||76|6.79|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|76||||76|52.44|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|76||||76|4.48|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76||||76|3.58|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76||||76|4.9|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76||||76|3.01|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76||||76|3.58|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76||||76|4.9|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76||||76|3.01|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|76||||76|3.01|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|76||||76|52.44|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76||||76|3.01|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|Self-pay|Self-pay|76||||76|26.6|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|76||||76|3.01|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76||||76|3.01|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76||||76|5|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|76||||76|3.58|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|76||||76|3.58|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76||||76|5|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76||||76|3.58|52.44|3.01
30183986|EAP|0301 - LABORATORY-CHEMISTRY|HC PH BODY FLUID NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76||||76|7.16|52.44|3.01
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|AARP [1000]|AARP [100000]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|AETNA [1015]|AETNA [101529]|358||||358|26.86|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|BCBS [1155]|BCBS UTHCT [115568]|358||||358|168.26|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|358||||358|29.57|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|358||||358|179|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|358||||358|225.54|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|CIGNA [1260]|CIGNA GWH [126023]|358||||358|22.67|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|358||||358|247.02|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|358||||358|24.54|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|358||||358|26.86|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|358||||358|26.86|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|358||||358|247.02|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|Self-pay|Self-pay|358||||358|125.3|247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|358||||358||247.02|22.67
30183993|EAP|0301 - LABORATORY-CHEMISTRY|HC CALPROTECTIN FECAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|358||||358||247.02|22.67
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|AARP [1000]|AARP [100000]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|AETNA [1015]|AETNA [101529]|96||||96|13.22|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|BCBS [1155]|BCBS UTHCT [115568]|96||||96|45.12|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|96||||96|14.55|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|96||||96|48|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|96||||96|60.48|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|CIGNA [1260]|CIGNA GWH [126023]|96||||96|11.33|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|96||||96|66.24|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|96||||96|12.08|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|96||||96|13.22|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|96||||96|13.22|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|96||||96|66.24|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|Self-pay|Self-pay|96||||96|33.6|66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|96||||96||66.24|11.33
30184066|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTATIC ACID PHOSPHATASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|96||||96||66.24|11.33
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AARP [1000]|AARP [100000]|106||||106|7.23|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|106||||106|5.23|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AETNA [1015]|AETNA [101529]|106||||106|7.08|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|106||||106|4.35|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|106||||106|5.18|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|106||||106|5.18|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS [1155]|BCBS UTHCT [115568]|106||||106|49.82|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|106||||106|7.8|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|106||||106|53|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|106||||106|66.78|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|106||||106|4.35|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|106||||106|5.18|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|CIGNA [1260]|CIGNA GWH [126023]|106||||106|5.95|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|106||||106|73.14|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|106||||106|6.48|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|106||||106|5.18|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106||||106|7.08|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|106||||106|4.35|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|106||||106|5.18|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|106||||106|7.08|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|106||||106|4.35|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|106||||106|4.35|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|106||||106|73.14|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|106||||106|4.35|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|Self-pay|Self-pay|106||||106|37.1|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|106||||106|4.35|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|106||||106|4.35|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|106||||106|7.23|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|106||||106|5.18|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|106||||106|5.18|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|106||||106|7.23|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|106||||106|5.18|73.14|4.35
30184075|EAP|0301 - LABORATORY-CHEMISTRY|HC ALKALINE PHOSPHATASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|106||||106|10.36|73.14|4.35
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|AARP [1000]|AARP [100000]|203||||203|20.66|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|203||||203|14.93|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|AETNA [1015]|AETNA [101529]|203||||203|20.21|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|203||||203|12.42|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|203||||203|14.78|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|203||||203|14.78|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|BCBS [1155]|BCBS UTHCT [115568]|203||||203|95.41|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|203||||203|22.27|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|203||||203|101.5|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|203||||203|127.89|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|203||||203|12.42|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|203||||203|14.78|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|CIGNA [1260]|CIGNA GWH [126023]|203||||203|17.28|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|203||||203|140.07|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|203||||203|18.48|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|203||||203|14.78|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|203||||203|20.21|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|203||||203|12.42|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|203||||203|14.78|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|203||||203|20.21|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|203||||203|12.42|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|203||||203|12.42|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|203||||203|140.07|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|203||||203|12.42|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|Self-pay|Self-pay|203||||203|71.05|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|203||||203|12.42|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|203||||203|12.42|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|203||||203|20.66|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|203||||203|14.78|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|203||||203|14.78|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|203||||203|20.66|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|203||||203|14.78|140.07|12.42
30184080|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHATASE ALKALINE ISOENZYM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|203||||203|29.56|140.07|12.42
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AARP [1000]|AARP [100000]|119||||119|6.63|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|119||||119|4.79|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AETNA [1015]|AETNA [101529]|119||||119|6.48|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|119||||119|3.98|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|119||||119|4.74|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|119||||119|4.74|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BCBS UTHCT [115568]|119||||119|55.93|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|119||||119|7.14|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|119||||119|59.5|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|119||||119|74.97|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|119||||119|3.98|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|119||||119|4.74|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|CIGNA [1260]|CIGNA GWH [126023]|119||||119|5.39|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|119||||119|82.11|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|119||||119|5.93|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|119||||119|4.74|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|119||||119|6.48|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|119||||119|3.98|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|119||||119|4.74|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|119||||119|6.48|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|119||||119|3.98|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|119||||119|3.98|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|119||||119|82.11|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|119||||119|3.98|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|Self-pay|Self-pay|119||||119|41.65|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|119||||119|3.98|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|119||||119|3.98|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|119||||119|6.63|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|119||||119|4.74|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|119||||119|4.74|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|119||||119|6.63|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|119||||119|4.74|82.11|3.98
30184100|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|119||||119|9.48|82.11|3.98
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|AARP [1000]|AARP [100000]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|AETNA [1015]|AETNA [101529]|106||||106|7.9|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|BCBS [1155]|BCBS UTHCT [115568]|106||||106|49.82|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|106||||106|7.8|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|106||||106|53|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|106||||106|66.78|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|CIGNA [1260]|CIGNA GWH [126023]|106||||106|5.95|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|106||||106|73.14|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|106||||106|7.23|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106||||106|7.9|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|106||||106|7.9|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|106||||106|73.14|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|Self-pay|Self-pay|106||||106|37.1|73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|106||||106||73.14|5.95
30184105|EAP|0301 - LABORATORY-CHEMISTRY|HC PHOSPHORUS INORGANIC URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|106||||106||73.14|5.95
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|AARP [1000]|AARP [100000]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|AETNA [1015]|AETNA [101529]|40||||40|11.54|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|BCBS [1155]|BCBS UTHCT [115568]|40||||40|18.8|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40||||40|12.71|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40||||40|20|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40||||40|25.2|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|CIGNA [1260]|CIGNA GWH [126023]|40||||40|9.92|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|40||||40|27.6|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|40||||40|10.55|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40||||40|11.54|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40||||40|11.54|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|40||||40|27.6|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|Self-pay|Self-pay|40||||40|14|27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40||||40||27.6|9.92
30184110|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHOBILINOGEN URINE QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40||||40||27.6|9.92
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|AARP [1000]|AARP [100000]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|AETNA [1015]|AETNA [101529]|36||||36|20.11|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|BCBS [1155]|BCBS UTHCT [115568]|36||||36|16.92|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|22.16|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|18|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|22.68|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|CIGNA [1260]|CIGNA GWH [126023]|36||||36|16.99|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|36||||36|18.39|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|20.11|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|20.11|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|Self-pay|Self-pay|36||||36|12.6|24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36||24.84|12.6
30184120|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS URINE QN & FRACTN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36||||36||24.84|12.6
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|AARP [1000]|AARP [100000]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|AETNA [1015]|AETNA [101529]|162||||162|53.5|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|BCBS [1155]|BCBS UTHCT [115568]|162||||162|76.14|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|162||||162|47.71|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|162||||162|81|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|162||||162|102.06|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|CIGNA [1260]|CIGNA GWH [126023]|162||||162|29.46|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|162||||162|111.78|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|162||||162|48.89|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|162||||162|53.5|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|162||||162|53.5|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|162||||162|111.78|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|Self-pay|Self-pay|162||||162|56.7|111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|162||||162||111.78|29.46
30184126|EAP|0301 - LABORATORY-CHEMISTRY|HC PORPHYRINS FECES QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|162||||162||111.78|29.46
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AARP [1000]|AARP [100000]|114||||114|6.42|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|114||||114|4.81|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AETNA [1015]|AETNA [101529]|114||||114|6.5|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|114||||114|4|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|114||||114|4.76|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|114||||114|4.76|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BCBS UTHCT [115568]|114||||114|53.58|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|114||||114|6.93|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|114||||114|57|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|114||||114|71.82|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|114||||114|4|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|114||||114|4.76|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|CIGNA [1260]|CIGNA GWH [126023]|114||||114|8.62|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|114||||114|78.66|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|114||||114|5.95|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|114||||114|4.76|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|114||||114|6.5|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|114||||114|4|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|114||||114|4.76|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|114||||114|6.5|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|114||||114|4|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|114||||114|4|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|114||||114|78.66|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|114||||114|4|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|Self-pay|Self-pay|114||||114|39.9|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|114||||114|4|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|114||||114|4|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|114||||114|6.42|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|114||||114|4.76|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|114||||114|4.76|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|114||||114|6.42|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|114||||114|4.76|78.66|4
30184132|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|114||||114|9.52|78.66|4
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AARP [1000]|AARP [100000]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AETNA [1015]|AETNA [101529]|148||||148|6.48|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS [1155]|BCBS UTHCT [115568]|148||||148|69.56|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|148||||148|6.49|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|148||||148|74|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|148||||148|93.24|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|CIGNA [1260]|CIGNA GWH [126023]|148||||148|5.1|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|148||||148|102.12|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|148||||148|5.91|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|148||||148|6.48|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|148||||148|6.48|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|148||||148|102.12|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|Self-pay|Self-pay|148||||148|51.8|102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|148||||148||102.12|5.1
30184133|EAP|0301 - LABORATORY-CHEMISTRY|HC POTASSIUM URINE RANDOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|148||||148||102.12|5.1
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AARP [1000]|AARP [100000]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AETNA [1015]|AETNA [101529]|196||||196|19.97|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BCBS UTHCT [115568]|196||||196|92.12|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|196||||196|21.97|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|196||||196|98|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|196||||196|123.48|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|CIGNA [1260]|CIGNA GWH [126023]|196||||196|16.99|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|196||||196|135.24|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|196||||196|18.24|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|196||||196|19.97|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|196||||196|19.97|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|196||||196|135.24|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|Self-pay|Self-pay|196||||196|68.6|135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|196||||196||135.24|16.99
30184134|EAP|0301 - LABORATORY-CHEMISTRY|HC PREALBUMIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|196||||196||135.24|16.99
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|AARP [1000]|AARP [100000]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|AETNA [1015]|AETNA [101529]|211||||211|28.27|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|BCBS [1155]|BCBS UTHCT [115568]|211||||211|99.17|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|211||||211|31.13|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|211||||211|105.5|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|211||||211|132.93|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|CIGNA [1260]|CIGNA GWH [126023]|211||||211|24.07|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|211||||211|145.59|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|211||||211|25.84|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|211||||211|28.27|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|211||||211|28.27|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|211||||211|145.59|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|Self-pay|Self-pay|211||||211|73.85|145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|211||||211||145.59|24.07
30184140|EAP|0301 - LABORATORY-CHEMISTRY|HC PREGNENOLONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|211||||211||145.59|24.07
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|AARP [1000]|AARP [100000]|250||||250|29.15|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|250||||250|21.07|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|AETNA [1015]|AETNA [101529]|250||||250|28.54|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|250||||250|17.52|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|250||||250|20.86|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|250||||250|20.86|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|BCBS [1155]|BCBS UTHCT [115568]|250||||250|117.5|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|250||||250|31.43|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|250||||250|125|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|250||||250|157.5|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|250||||250|17.52|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|250||||250|20.86|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|CIGNA [1260]|CIGNA GWH [126023]|250||||250|24.36|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|250||||250|172.5|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|250||||250|26.08|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|250||||250|20.86|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|250||||250|28.54|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|250||||250|17.52|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|250||||250|20.86|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|250||||250|28.54|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|250||||250|17.52|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|250||||250|17.52|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|250||||250|172.5|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|250||||250|17.52|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|Self-pay|Self-pay|250||||250|87.5|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|250||||250|17.52|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|250||||250|17.52|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|250||||250|29.15|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|250||||250|20.86|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|250||||250|20.86|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|250||||250|29.15|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|250||||250|20.86|172.5|17.52
30184144|EAP|0301 - LABORATORY-CHEMISTRY|HC PROGESTERONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|250||||250|41.72|172.5|17.52
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AARP [1000]|AARP [100000]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AETNA [1015]|AETNA [101529]|360||||360|37.25|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BCBS UTHCT [115568]|360||||360|169.2|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|360||||360|40.36|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|360||||360|180|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|360||||360|226.8|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|CIGNA [1260]|CIGNA GWH [126023]|360||||360|198|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|360||||360|248.4|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|360||||360|34.03|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|360||||360|37.25|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|360||||360|37.25|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|360||||360|248.4|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|Self-pay|Self-pay|360||||360|126|248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|360||||360||248.4|34.03
30184145|EAP|0301 - LABORATORY-CHEMISTRY|HC PROCALCITONIN (PCT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|360||||360||248.4|34.03
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AARP [1000]|AARP [100000]|294||||294|27.08|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|294||||294|19.57|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AETNA [1015]|AETNA [101529]|294||||294|26.52|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|294||||294|16.28|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|294||||294|19.38|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|294||||294|19.38|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS [1155]|BCBS UTHCT [115568]|294||||294|138.18|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|294||||294|29.18|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|294||||294|147|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|294||||294|185.22|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|294||||294|16.28|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|294||||294|19.38|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|CIGNA [1260]|CIGNA GWH [126023]|294||||294|22.38|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|294||||294|202.86|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|294||||294|24.23|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|294||||294|19.38|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|294||||294|26.52|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|294||||294|16.28|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|294||||294|19.38|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|294||||294|26.52|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|294||||294|16.28|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|294||||294|16.28|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|294||||294|202.86|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|294||||294|16.28|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|Self-pay|Self-pay|294||||294|102.9|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|294||||294|16.28|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|294||||294|16.28|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|294||||294|27.08|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|294||||294|19.38|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|294||||294|19.38|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|294||||294|27.08|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|294||||294|19.38|202.86|16.28
30184146|EAP|0301 - LABORATORY-CHEMISTRY|HC PROLACTIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|294||||294|38.76|202.86|16.28
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|AARP [1000]|AARP [100000]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|AETNA [1015]|AETNA [101529]|419||||419|57.14|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|BCBS [1155]|BCBS UTHCT [115568]|419||||419|196.93|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|419||||419|50.96|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|419||||419|209.5|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|419||||419|263.97|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|CIGNA [1260]|CIGNA GWH [126023]|419||||419|28.9|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|419||||419|289.11|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|419||||419|52.21|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|419||||419|57.14|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|419||||419|57.14|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|419||||419|289.11|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|Self-pay|Self-pay|419||||419|146.65|289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|419||||419||289.11|28.9
30184150|EAP|0301 - LABORATORY-CHEMISTRY|HC PROSTAGLANDIN EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|419||||419||289.11|28.9
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AARP [1000]|AARP [100000]|210||||210|25.7|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|210||||210|18.57|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AETNA [1015]|AETNA [101529]|210||||210|25.15|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|210||||210|15.45|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|210||||210|18.39|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|210||||210|18.39|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|210||||210|98.7|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|210||||210|27.71|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|210||||210|105|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|210||||210|132.3|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|210||||210|15.45|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|210||||210|18.39|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|210||||210|21.24|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|210||||210|144.9|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|210||||210|22.99|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|210||||210|18.39|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|210||||210|25.15|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|210||||210|15.45|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|210||||210|18.39|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|210||||210|25.15|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|210||||210|15.45|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|210||||210|15.45|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|210||||210|144.9|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|210||||210|15.45|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|Self-pay|Self-pay|210||||210|73.5|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|210||||210|15.45|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|210||||210|15.45|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|210||||210|25.7|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|210||||210|18.39|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|210||||210|18.39|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|210||||210|25.7|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|210||||210|18.39|144.9|15.45
30184153|EAP|0301 - LABORATORY-CHEMISTRY|HC AG PROSTATE SPECIFIC(PSA) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|210||||210|36.78|144.9|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AARP [1000]|AARP [100000]|226||||226|25.7|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|226||||226|18.57|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AETNA [1015]|AETNA [101529]|226||||226|25.15|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|226||||226|15.45|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|226||||226|18.39|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|226||||226|18.39|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS [1155]|BCBS UTHCT [115568]|226||||226|106.22|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|226||||226|27.71|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|226||||226|113|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|226||||226|142.38|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|226||||226|15.45|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|226||||226|18.39|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|CIGNA [1260]|CIGNA GWH [126023]|226||||226|21.24|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|226||||226|155.94|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|226||||226|22.99|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|226||||226|18.39|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|226||||226|25.15|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|226||||226|15.45|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|226||||226|18.39|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|226||||226|25.15|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|226||||226|15.45|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|226||||226|15.45|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|226||||226|155.94|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|226||||226|15.45|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|Self-pay|Self-pay|226||||226|79.1|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|226||||226|15.45|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|226||||226|15.45|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|226||||226|25.7|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|226||||226|18.39|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|226||||226|18.39|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|226||||226|25.7|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|226||||226|18.39|155.94|15.45
30184154|EAP|0301 - LABORATORY-CHEMISTRY|HC LAB AG PROSTATE (PSA) FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|226||||226|36.78|155.94|15.45
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AARP [1000]|AARP [100000]|99||||99|5.12|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99||||99|3.71|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AETNA [1015]|AETNA [101529]|99||||99|5.02|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99||||99|3.08|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99||||99|3.67|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99||||99|3.67|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BCBS UTHCT [115568]|99||||99|46.53|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99||||99|5.53|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99||||99|49.5|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99||||99|62.37|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99||||99|3.08|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99||||99|3.67|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|CIGNA [1260]|CIGNA GWH [126023]|99||||99|4.25|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|99||||99|68.31|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|99||||99|4.59|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99||||99|3.67|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99||||99|5.02|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99||||99|3.08|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99||||99|3.67|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99||||99|5.02|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99||||99|3.08|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|99||||99|3.08|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|99||||99|68.31|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99||||99|3.08|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|Self-pay|Self-pay|99||||99|34.65|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|99||||99|3.08|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99||||99|3.08|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99||||99|5.12|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|99||||99|3.67|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|99||||99|3.67|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99||||99|5.12|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99||||99|3.67|68.31|3.08
30184155|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99||||99|7.34|68.31|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AARP [1000]|AARP [100000]|94||||94|5.12|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94||||94|3.71|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AETNA [1015]|AETNA [101529]|94||||94|5.02|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94||||94|3.08|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94||||94|3.67|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|94||||94|3.67|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BCBS UTHCT [115568]|94||||94|44.18|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|94||||94|5.53|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94||||94|47|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|94||||94|59.22|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|94||||94|3.08|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94||||94|3.67|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|CIGNA [1260]|CIGNA GWH [126023]|94||||94|4.25|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|94||||94|64.86|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|94||||94|4.59|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|94||||94|3.67|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94||||94|5.02|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94||||94|3.08|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94||||94|3.67|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94||||94|5.02|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|94||||94|3.08|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|94||||94|3.08|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|94||||94|64.86|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94||||94|3.08|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|Self-pay|Self-pay|94||||94|32.9|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|94||||94|3.08|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|94||||94|3.08|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94||||94|5.12|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|94||||94|3.67|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|94||||94|3.67|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94||||94|5.12|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94||||94|3.67|64.86|3.08
30184156|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|94||||94|7.34|64.86|3.08
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AARP [1000]|AARP [100000]|121||||121|5.12|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|121||||121|4.04|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AETNA [1015]|AETNA [101529]|121||||121|5.47|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|121||||121|3.36|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|121||||121|4|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|121||||121|4|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BCBS UTHCT [115568]|121||||121|56.87|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|121||||121|5.53|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|121||||121|60.5|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|121||||121|76.23|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|121||||121|3.36|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|121||||121|4|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|CIGNA [1260]|CIGNA GWH [126023]|121||||121|4.25|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|121||||121|83.49|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|121||||121|5|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|121||||121|4|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|121||||121|5.47|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|121||||121|3.36|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|121||||121|4|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|121||||121|5.47|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|121||||121|3.36|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|121||||121|3.36|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|121||||121|83.49|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|121||||121|3.36|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|Self-pay|Self-pay|121||||121|42.35|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|121||||121|3.36|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|121||||121|3.36|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|121||||121|5.12|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|121||||121|4|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|121||||121|4|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|121||||121|5.12|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|121||||121|4|83.49|3.36
30184157|EAP|0301 - LABORATORY-CHEMISTRY|HC TOTAL PROTEIN BODY FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|121||||121|8|83.49|3.36
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|AARP [1000]|AARP [100000]|151||||151|7.23|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|151||||151|5.67|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|AETNA [1015]|AETNA [101529]|151||||151|7.68|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|151||||151|4.71|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|151||||151|5.61|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|151||||151|5.61|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|BCBS [1155]|BCBS UTHCT [115568]|151||||151|70.97|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|151||||151|7.8|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|151||||151|75.5|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|151||||151|95.13|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|151||||151|4.71|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|151||||151|5.61|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|CIGNA [1260]|CIGNA GWH [126023]|151||||151|5.95|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|151||||151|104.19|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|151||||151|7.01|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|151||||151|5.61|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|151||||151|7.68|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|151||||151|4.71|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|151||||151|5.61|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|151||||151|7.68|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|151||||151|4.71|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|151||||151|4.71|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|151||||151|104.19|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|151||||151|4.71|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|Self-pay|Self-pay|151||||151|52.85|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|151||||151|4.71|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|151||||151|4.71|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|151||||151|7.23|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|151||||151|5.61|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|151||||151|5.61|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|151||||151|7.23|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|151||||151|5.61|104.19|4.71
30184160|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN TOTAL REFRACTOMETRY ANY SRC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|151||||151|11.22|104.19|4.71
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AARP [1000]|AARP [100000]|174||||174|15.01|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|174||||174|10.85|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AETNA [1015]|AETNA [101529]|174||||174|14.69|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|174||||174|9.02|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|174||||174|10.74|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|174||||174|10.74|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS [1155]|BCBS UTHCT [115568]|174||||174|81.78|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|174||||174|16.18|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|174||||174|87|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|174||||174|109.62|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|174||||174|9.02|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|174||||174|10.74|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|CIGNA [1260]|CIGNA GWH [126023]|174||||174|25.57|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|174||||174|120.06|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|174||||174|13.43|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|174||||174|10.74|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|174||||174|14.69|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|174||||174|9.02|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|174||||174|10.74|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|174||||174|14.69|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|174||||174|9.02|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|174||||174|9.02|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|174||||174|120.06|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|174||||174|9.02|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|Self-pay|Self-pay|174||||174|60.9|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|174||||174|9.02|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|174||||174|9.02|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|174||||174|15.01|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|174||||174|10.74|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|174||||174|10.74|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|174||||174|15.01|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|174||||174|10.74|120.06|9.02
30184165|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHORESIS SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|174||||174|21.48|120.06|9.02
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AARP [1000]|AARP [100000]|255||||255|24.92|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|255||||255|18.01|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AETNA [1015]|AETNA [101529]|255||||255|24.38|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|255||||255|14.98|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|255||||255|17.83|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|255||||255|17.83|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS [1155]|BCBS UTHCT [115568]|255||||255|119.85|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|255||||255|26.85|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|255||||255|127.5|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|255||||255|160.65|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|255||||255|14.98|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|255||||255|17.83|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|CIGNA [1260]|CIGNA GWH [126023]|255||||255|33.78|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|255||||255|175.95|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|255||||255|22.29|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|255||||255|17.83|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|255||||255|24.38|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|255||||255|14.98|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|255||||255|17.83|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|255||||255|24.38|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|255||||255|14.98|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|255||||255|14.98|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|255||||255|175.95|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|255||||255|14.98|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|Self-pay|Self-pay|255||||255|89.25|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|255||||255|14.98|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|255||||255|14.98|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|255||||255|24.92|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|255||||255|17.83|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|255||||255|17.83|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|255||||255|24.92|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|255||||255|17.83|175.95|14.98
30184166|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN ELECTROPHOR FLD W/CON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|255||||255|35.66|175.95|14.98
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AARP [1000]|AARP [100000]|288||||288|25.15|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|288||||288|29.5|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AETNA [1015]|AETNA [101529]|288||||288|39.96|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|288||||288|24.54|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|288||||288|29.21|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|288||||288|29.21|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BCBS UTHCT [115568]|288||||288|135.36|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|288||||288|35.64|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|288||||288|144|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|288||||288|181.44|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|288||||288|24.54|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|288||||288|29.21|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|CIGNA [1260]|CIGNA GWH [126023]|288||||288|34.64|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|288||||288|198.72|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|288||||288|36.51|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|288||||288|29.21|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|288||||288|39.96|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|288||||288|24.54|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|288||||288|29.21|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|288||||288|39.96|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|288||||288|24.54|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|288||||288|24.54|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|288||||288|198.72|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|288||||288|24.54|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|Self-pay|Self-pay|288||||288|100.8|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|288||||288|24.54|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|288||||288|24.54|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|288||||288|25.15|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|288||||288|29.21|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|288||||288|29.21|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|288||||288|25.15|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|288||||288|29.21|198.72|24.54
30184182|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTEIN WESTERN BLOT BAND ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|288||||288|58.42|198.72|24.54
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|AARP [1000]|AARP [100000]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|AETNA [1015]|AETNA [101529]|70||||70|19.63|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|BCBS [1155]|BCBS UTHCT [115568]|70||||70|32.9|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70||||70|21.61|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70||||70|35|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70||||70|44.1|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|CIGNA [1260]|CIGNA GWH [126023]|70||||70|16.72|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70||||70|48.3|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70||||70|17.94|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70||||70|19.63|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70||||70|19.63|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70||||70|48.3|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|Self-pay|Self-pay|70||||70|24.5|48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70||||70||48.3|16.72
30184202|EAP|0301 - LABORATORY-CHEMISTRY|HC PROTOPORPHYRIN RBC QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70||||70||48.3|16.72
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|AARP [1000]|AARP [100000]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|AETNA [1015]|AETNA [101529]|159||||159|36.5|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|BCBS [1155]|BCBS UTHCT [115568]|159||||159|74.73|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|159||||159|32.56|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|159||||159|79.5|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|159||||159|100.17|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|CIGNA [1260]|CIGNA GWH [126023]|159||||159|20.68|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|159||||159|109.71|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|159||||159|33.36|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|159||||159|36.5|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|159||||159|36.5|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|159||||159|109.71|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|Self-pay|Self-pay|159||||159|55.65|109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|159||||159||109.71|20.68
30184206|EAP|0301 - LABORATORY-CHEMISTRY|HC PROINSULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|159||||159||109.71|20.68
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AARP [1000]|AARP [100000]|320||||320|39.25|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|320||||320|28.38|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AETNA [1015]|AETNA [101529]|320||||320|38.45|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|320||||320|23.6|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|320||||320|28.1|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|320||||320|28.1|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS [1155]|BCBS UTHCT [115568]|320||||320|150.4|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|320||||320|42.32|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|320||||320|160|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|320||||320|201.6|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|320||||320|23.6|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|320||||320|28.1|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|CIGNA [1260]|CIGNA GWH [126023]|320||||320|32.57|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|GROUP PENSION ADMIN [1450]|GPA [145000]|320||||320|220.8|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|320||||320|35.13|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|320||||320|28.1|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|320||||320|38.45|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|320||||320|23.6|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|320||||320|28.1|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|320||||320|38.45|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|320||||320|23.6|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|320||||320|23.6|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|PHCS [1780]|PHCS MULTIPLAN [178000]|320||||320|220.8|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|320||||320|23.6|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|Self-pay|Self-pay|320||||320|112|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|320||||320|23.6|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|320||||320|23.6|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|320||||320|39.25|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|320||||320|28.1|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|320||||320|28.1|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|320||||320|39.25|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|320||||320|28.1|220.8|23.6
30184207|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-6|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|320||||320|56.2|220.8|23.6
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|AARP [1000]|AARP [100000]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|AETNA [1015]|AETNA [101529]|29||||29|19.8|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|BCBS [1155]|BCBS UTHCT [115568]|29||||29|13.63|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29||||29|17.67|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29||||29|14.5|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29||||29|18.27|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|CIGNA [1260]|CIGNA GWH [126023]|29||||29|12.74|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|29||||29|20.01|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29||||29|18.1|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29||||29|19.8|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29||||29|19.8|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|29||||29|20.01|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|Self-pay|Self-pay|29||||29|10.15|20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29||||29||20.01|10.15
30184210|EAP|0301 - LABORATORY-CHEMISTRY|HC PYRUVATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29||||29||20.01|10.15
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|AARP [1000]|AARP [100000]|73||||73|51.09|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|73||||73|36.94|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|AETNA [1015]|AETNA [101529]|73||||73|50.02|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|73||||73|30.72|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|73||||73|36.57|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|73||||73|36.57|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|BCBS [1155]|BCBS UTHCT [115568]|73||||73|34.31|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|73||||73|55.07|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|73||||73|36.5|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|73||||73|45.99|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|73||||73|30.72|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|73||||73|36.57|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|CIGNA [1260]|CIGNA GWH [126023]|73||||73|42.49|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|73||||73|50.37|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|73||||73|45.71|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|73||||73|36.57|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|73||||73|50.02|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|73||||73|30.72|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|73||||73|36.57|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|73||||73|50.02|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|73||||73|30.72|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|73||||73|30.72|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|73||||73|50.37|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|73||||73|30.72|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|Self-pay|Self-pay|73||||73|25.55|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|73||||73|30.72|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|73||||73|30.72|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|73||||73|51.09|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|73||||73|36.57|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|73||||73|36.57|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|73||||73|51.09|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|73||||73|36.57|73.14|25.55
30184238|EAP|0301 - LABORATORY-CHEMISTRY|HC RECEPTOR ASSAY NON-ENDOCRINE(SPECIFY RECEPTOR)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|73||||73|73.14|73.14|25.55
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AARP [1000]|AARP [100000]|348||||348|30.73|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|348||||348|22.21|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AETNA [1015]|AETNA [101529]|348||||348|30.07|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|348||||348|18.47|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|348||||348|21.99|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|348||||348|21.99|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BCBS UTHCT [115568]|348||||348|163.56|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|348||||348|33.12|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|348||||348|174|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|348||||348|219.24|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|348||||348|18.47|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|348||||348|21.99|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|CIGNA [1260]|CIGNA GWH [126023]|348||||348|25.49|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|348||||348|240.12|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|348||||348|27.49|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|348||||348|21.99|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|348||||348|30.07|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|348||||348|18.47|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|348||||348|21.99|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|348||||348|30.07|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|348||||348|18.47|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|348||||348|18.47|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|348||||348|240.12|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|348||||348|18.47|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|Self-pay|Self-pay|348||||348|121.8|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|348||||348|18.47|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|348||||348|18.47|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|348||||348|30.73|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|348||||348|21.99|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|348||||348|21.99|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|348||||348|30.73|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|348||||348|21.99|240.12|18.47
30184244|EAP|0301 - LABORATORY-CHEMISTRY|HC RENIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|348||||348|43.98|240.12|18.47
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|AARP [1000]|AARP [100000]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|AETNA [1015]|AETNA [101529]|194||||194|27.7|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|BCBS [1155]|BCBS UTHCT [115568]|194||||194|91.18|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|194||||194|30.48|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|194||||194|97|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|194||||194|122.22|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|CIGNA [1260]|CIGNA GWH [126023]|194||||194|23.52|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|194||||194|133.86|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|194||||194|25.3|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|194||||194|27.7|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|194||||194|27.7|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|194||||194|133.86|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|Self-pay|Self-pay|194||||194|67.9|133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|194||||194||133.86|23.52
30184252|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B-2 (RIBOFLAVIN)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|194||||194||133.86|23.52
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|AARP [1000]|AARP [100000]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|AETNA [1015]|AETNA [101529]|116||||116|34.92|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|38.45|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|29.75|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|31.91|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|34.92|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|34.92|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|Self-pay|Self-pay|116||||116|40.6|80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116||80.04|29.75
30184255|EAP|0301 - LABORATORY-CHEMISTRY|HC SELENIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116||80.04|29.75
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|AARP [1000]|AARP [100000]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|AETNA [1015]|AETNA [101529]|754||||754|42.38|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|BCBS [1155]|BCBS UTHCT [115568]|754||||754|354.38|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|754||||754|46.67|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|754||||754|377|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|754||||754|475.02|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|CIGNA [1260]|CIGNA GWH [126023]|754||||754|35.98|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|754||||754|520.26|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|754||||754|38.73|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|754||||754|42.38|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|754||||754|42.38|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|754||||754|520.26|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|Self-pay|Self-pay|754||||754|263.9|520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|754||||754||520.26|35.98
30184260|EAP|0301 - LABORATORY-CHEMISTRY|HC SEROTONIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|754||||754||520.26|35.98
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|AARP [1000]|AARP [100000]|53||||53|30.36|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|53||||53|21.95|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|AETNA [1015]|AETNA [101529]|53||||53|29.74|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|53||||53|18.25|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|53||||53|21.73|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|53||||53|21.73|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|BCBS [1155]|BCBS UTHCT [115568]|53||||53|24.91|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|53||||53|32.73|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|53||||53|26.5|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|53||||53|33.39|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|53||||53|18.25|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|53||||53|21.73|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|CIGNA [1260]|CIGNA GWH [126023]|53||||53|25.21|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|53||||53|36.57|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|53||||53|27.16|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|53||||53|21.73|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|53||||53|29.74|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|53||||53|18.25|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|53||||53|21.73|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|53||||53|29.74|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|53||||53|18.25|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|53||||53|18.25|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|53||||53|36.57|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|53||||53|18.25|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|Self-pay|Self-pay|53||||53|18.55|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|53||||53|18.25|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|53||||53|18.25|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|53||||53|30.36|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|53||||53|21.73|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|53||||53|21.73|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|53||||53|30.36|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|53||||53|21.73|43.46|18.25
30184270|EAP|0301 - LABORATORY-CHEMISTRY|HC SEX HORMONE BINDING GLOBULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|53||||53|43.46|43.46|18.25
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AARP [1000]|AARP [100000]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AETNA [1015]|AETNA [101529]|96||||96|6.58|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BCBS UTHCT [115568]|96||||96|45.12|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|96||||96|7.25|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|96||||96|48|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|96||||96|60.48|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|CIGNA [1260]|CIGNA GWH [126023]|96||||96|5.66|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|96||||96|66.24|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|96||||96|6.01|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|96||||96|6.58|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|96||||96|6.58|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|96||||96|66.24|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|Self-pay|Self-pay|96||||96|33.6|66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|96||||96||66.24|5.66
30184295|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM SERUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|96||||96||66.24|5.66
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AARP [1000]|AARP [100000]|117||||117|6.79|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|117||||117|5.11|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AETNA [1015]|AETNA [101529]|117||||117|6.91|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|117||||117|4.25|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|117||||117|5.06|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|117||||117|5.06|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BCBS UTHCT [115568]|117||||117|54.99|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|117||||117|7.32|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|117||||117|58.5|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|117||||117|73.71|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|117||||117|4.25|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|117||||117|5.06|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|CIGNA [1260]|CIGNA GWH [126023]|117||||117|5.66|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|117||||117|80.73|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|117||||117|6.33|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|117||||117|5.06|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|117||||117|6.91|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|117||||117|4.25|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|117||||117|5.06|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|117||||117|6.91|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|117||||117|4.25|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|117||||117|4.25|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|117||||117|80.73|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|117||||117|4.25|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|Self-pay|Self-pay|117||||117|40.95|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|117||||117|4.25|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|117||||117|4.25|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|117||||117|6.79|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|117||||117|5.06|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|117||||117|5.06|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|117||||117|6.79|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|117||||117|5.06|80.73|4.25
30184300|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM URINE RANDOM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|117||||117|10.12|80.73|4.25
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|AARP [1000]|AARP [100000]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|108||||108|6.65|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|BCBS [1155]|BCBS UTHCT [115568]|108||||108|50.76|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108||||108|7.32|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108||||108|54|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108||||108|68.04|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|CIGNA [1260]|CIGNA GWH [126023]|108||||108|5.66|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|108||||108|74.52|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|108||||108|6.08|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108||||108|6.65|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108||||108|6.65|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|108||||108|74.52|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|Self-pay|Self-pay|108||||108|37.8|74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108||||108||74.52|5.66
30184302|EAP|0301 - LABORATORY-CHEMISTRY|HC SODIUM OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108||||108||74.52|5.66
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|AARP [1000]|AARP [100000]|47||||47|29.7|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|47||||47|21.47|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|AETNA [1015]|AETNA [101529]|47||||47|29.09|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|47||||47|17.86|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|47||||47|21.26|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|47||||47|21.26|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|BCBS [1155]|BCBS UTHCT [115568]|47||||47|22.09|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|47||||47|32.03|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|47||||47|23.5|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|47||||47|29.61|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|47||||47|17.86|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|47||||47|21.26|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|CIGNA [1260]|CIGNA GWH [126023]|47||||47|24.64|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|47||||47|32.43|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|47||||47|26.58|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|47||||47|21.26|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|47||||47|29.09|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|47||||47|17.86|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|47||||47|21.26|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|47||||47|29.09|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|47||||47|17.86|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|47||||47|17.86|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|47||||47|32.43|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|47||||47|17.86|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|Self-pay|Self-pay|47||||47|16.45|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|47||||47|17.86|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|47||||47|17.86|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|47||||47|29.7|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|47||||47|21.26|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|47||||47|21.26|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|47||||47|29.7|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|47||||47|21.26|42.52|16.45
30184305|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOMEDIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|47||||47|42.52|42.52|16.45
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|AARP [1000]|AARP [100000]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|AETNA [1015]|AETNA [101529]|213||||213|25.01|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|BCBS [1155]|BCBS UTHCT [115568]|213||||213|100.11|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|213||||213|27.52|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|213||||213|106.5|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|213||||213|134.19|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|CIGNA [1260]|CIGNA GWH [126023]|213||||213|21.24|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|213||||213|146.97|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|213||||213|22.85|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|213||||213|25.01|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|213||||213|25.01|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|213||||213|146.97|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|Self-pay|Self-pay|213||||213|74.55|146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|213||||213||146.97|21.24
30184307|EAP|0301 - LABORATORY-CHEMISTRY|HC SOMATOSTATIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|213||||213||146.97|21.24
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|AARP [1000]|AARP [100000]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|AETNA [1015]|AETNA [101529]|250||||250|11.09|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|BCBS [1155]|BCBS UTHCT [115568]|250||||250|117.5|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|250||||250|10.53|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|250||||250|125|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|250||||250|157.5|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|CIGNA [1260]|CIGNA GWH [126023]|250||||250|8.21|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|250||||250|172.5|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|250||||250|10.13|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|250||||250|11.09|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|250||||250|11.09|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|250||||250|172.5|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|Self-pay|Self-pay|250||||250|87.5|172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|250||||250||172.5|8.21
30184311|EAP|0301 - LABORATORY-CHEMISTRY|HC SPECTROPHOTOMETRY ANALYTE NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|250||||250||172.5|8.21
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|AARP [1000]|AARP [100000]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|AETNA [1015]|AETNA [101529]|24.4||||24.4|7.54|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|BCBS [1155]|BCBS UTHCT [115568]|24.4||||24.4|11.47|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.4||||24.4|8.28|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.4||||24.4|12.2|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.4||||24.4|15.37|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|CIGNA [1260]|CIGNA GWH [126023]|24.4||||24.4|6.5|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|24.4||||24.4|16.84|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.4||||24.4|6.88|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.4||||24.4|7.54|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.4||||24.4|7.54|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|24.4||||24.4|16.84|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|Self-pay|Self-pay|24.4||||24.4|8.54|16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.4||||24.4||16.84|6.5
30184376|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUALITATIVE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.4||||24.4||16.84|6.5
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|AARP [1000]|AARP [100000]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|AETNA [1015]|AETNA [101529]|123||||123|15.77|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|BCBS [1155]|BCBS UTHCT [115568]|123||||123|57.81|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|123||||123|17.36|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|123||||123|61.5|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|123||||123|77.49|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|CIGNA [1260]|CIGNA GWH [126023]|123||||123|13.32|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|123||||123|84.87|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|123||||123|14.41|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|123||||123|15.77|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|123||||123|15.77|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|123||||123|84.87|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|Self-pay|Self-pay|123||||123|43.05|84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|123||||123||84.87|13.32
30184378|EAP|0301 - LABORATORY-CHEMISTRY|HC SUGARS SINGLE QUANT EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|123||||123||84.87|13.32
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|AARP [1000]|AARP [100000]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|AETNA [1015]|AETNA [101529]|180||||180|7.51|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|BCBS [1155]|BCBS UTHCT [115568]|180||||180|84.6|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|180||||180|7.15|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|180||||180|90|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|180||||180|113.4|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|CIGNA [1260]|CIGNA GWH [126023]|180||||180|5.39|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|180||||180|124.2|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|180||||180|6.86|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|180||||180|7.51|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|180||||180|7.51|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|180||||180|124.2|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|Self-pay|Self-pay|180||||180|63|124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|180||||180||124.2|5.39
30184392|EAP|0301 - LABORATORY-CHEMISTRY|HC SULFATE URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|180||||180||124.2|5.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|AARP [1000]|AARP [100000]|64||||64|35.57|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|64||||64|25.72|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|AETNA [1015]|AETNA [101529]|64||||64|34.85|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|64||||64|21.39|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|64||||64|25.47|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|64||||64|25.47|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|BCBS [1155]|BCBS UTHCT [115568]|64||||64|30.08|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|64||||64|38.37|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|64||||64|32|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|64||||64|40.32|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|64||||64|21.39|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|64||||64|25.47|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|CIGNA [1260]|CIGNA GWH [126023]|64||||64|29.46|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|64||||64|44.16|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|64||||64|31.84|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|64||||64|25.47|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|64||||64|34.85|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|64||||64|21.39|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|64||||64|25.47|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|64||||64|34.85|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|64||||64|21.39|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|64||||64|21.39|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|64||||64|44.16|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|64||||64|21.39|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|Self-pay|Self-pay|64||||64|22.4|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|64||||64|21.39|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|64||||64|21.39|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|64||||64|35.57|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|64||||64|25.47|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|64||||64|25.47|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|64||||64|35.57|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|64||||64|25.47|50.94|21.39
30184402|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|64||||64|50.94|50.94|21.39
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AARP [1000]|AARP [100000]|235||||235|36.08|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|235||||235|26.07|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AETNA [1015]|AETNA [101529]|235||||235|35.3|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|235||||235|21.68|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|235||||235|25.81|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|235||||235|25.81|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS [1155]|BCBS UTHCT [115568]|235||||235|110.45|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|235||||235|38.88|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|235||||235|117.5|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|235||||235|148.05|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|235||||235|21.68|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|235||||235|25.81|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|CIGNA [1260]|CIGNA GWH [126023]|235||||235|30.02|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|235||||235|162.15|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|235||||235|32.26|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|235||||235|25.81|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|235||||235|35.3|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|235||||235|21.68|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|235||||235|25.81|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|235||||235|35.3|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|235||||235|21.68|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|235||||235|21.68|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|235||||235|162.15|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|235||||235|21.68|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|Self-pay|Self-pay|235||||235|82.25|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|235||||235|21.68|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|235||||235|21.68|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|235||||235|36.08|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|235||||235|25.81|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|235||||235|25.81|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|235||||235|36.08|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|235||||235|25.81|162.15|21.68
30184403|EAP|0301 - LABORATORY-CHEMISTRY|HC TESTOSTERONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|235||||235|51.62|162.15|21.68
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AARP [1000]|AARP [100000]|31||||31|29.67|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31|21.44|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AETNA [1015]|AETNA [101529]|31||||31|29.04|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|17.83|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31|21.23|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31|21.23|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|31|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|17.83|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31|21.23|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|CIGNA [1260]|CIGNA GWH [126023]|31||||31|24.64|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|26.54|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31|21.23|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|29.04|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|17.83|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31|21.23|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|29.04|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|17.83|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|17.83|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|17.83|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|Self-pay|Self-pay|31||||31|10.85|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|17.83|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|17.83|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31|29.67|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31|21.23|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31|21.23|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31|29.67|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31|21.23|42.46|10.85
30184425|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN B1 (THIAMINE)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31|42.46|42.46|10.85
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|AARP [1000]|AARP [100000]|147||||147|22.44|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|147||||147|16.22|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|AETNA [1015]|AETNA [101529]|147||||147|21.96|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|147||||147|13.49|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|147||||147|16.06|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|147||||147|16.06|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|BCBS [1155]|BCBS UTHCT [115568]|147||||147|69.09|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|147||||147|24.19|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|147||||147|73.5|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|147||||147|92.61|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|147||||147|13.49|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|147||||147|16.06|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|CIGNA [1260]|CIGNA GWH [126023]|147||||147|18.7|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|147||||147|101.43|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|147||||147|20.08|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|147||||147|16.06|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|147||||147|21.96|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|147||||147|13.49|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|147||||147|16.06|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|147||||147|21.96|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|147||||147|13.49|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|147||||147|13.49|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|147||||147|101.43|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|147||||147|13.49|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|Self-pay|Self-pay|147||||147|51.45|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|147||||147|13.49|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|147||||147|13.49|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|147||||147|22.44|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|147||||147|16.06|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|147||||147|16.06|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|147||||147|22.44|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|147||||147|16.06|101.43|13.49
30184432|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROGLOBULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|147||||147|32.12|101.43|13.49
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AARP [1000]|AARP [100000]|180||||180|9.61|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|180||||180|6.94|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AETNA [1015]|AETNA [101529]|180||||180|9.41|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|180||||180|5.77|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|180||||180|6.87|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|180||||180|6.87|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|180||||180|84.6|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|180||||180|10.35|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|180||||180|90|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|180||||180|113.4|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|180||||180|5.77|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|180||||180|6.87|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|180||||180|7.93|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|180||||180|124.2|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|180||||180|8.59|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|180||||180|6.87|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|180||||180|9.41|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|180||||180|5.77|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|180||||180|6.87|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|180||||180|9.41|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|180||||180|5.77|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|180||||180|5.77|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|180||||180|124.2|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|180||||180|5.77|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|Self-pay|Self-pay|180||||180|63|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|180||||180|5.77|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|180||||180|5.77|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|180||||180|9.61|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|180||||180|6.87|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|180||||180|6.87|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|180||||180|9.61|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|180||||180|6.87|124.2|5.77
30184436|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|180||||180|13.74|124.2|5.77
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AARP [1000]|AARP [100000]|263||||263|12.6|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|263||||263|9.11|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AETNA [1015]|AETNA [101529]|263||||263|12.34|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|263||||263|7.58|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|263||||263|9.02|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|263||||263|9.02|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BCBS UTHCT [115568]|263||||263|123.61|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|263||||263|13.58|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|263||||263|131.5|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|263||||263|165.69|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|263||||263|7.58|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|263||||263|9.02|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|CIGNA [1260]|CIGNA GWH [126023]|263||||263|10.49|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|263||||263|181.47|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|263||||263|11.28|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|263||||263|9.02|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|263||||263|12.34|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|263||||263|7.58|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|263||||263|9.02|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|263||||263|12.34|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|263||||263|7.58|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|263||||263|7.58|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|263||||263|181.47|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|263||||263|7.58|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|Self-pay|Self-pay|263||||263|92.05|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|263||||263|7.58|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|263||||263|7.58|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|263||||263|12.6|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|263||||263|9.02|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|263||||263|9.02|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|263||||263|12.6|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|263||||263|9.02|181.47|7.58
30184439|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE (T-4) FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|263||||263|18.04|181.47|7.58
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AARP [1000]|AARP [100000]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AETNA [1015]|AETNA [101529]|34||||34|20.21|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS [1155]|BCBS UTHCT [115568]|34||||34|15.98|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|22.27|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|21.42|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|CIGNA [1260]|CIGNA GWH [126023]|34||||34|17.28|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34||||34|18.48|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|20.21|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|20.21|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|Self-pay|Self-pay|34||||34|11.9|23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34||23.46|11.9
30184442|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROXINE BINDING GLOBULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34||23.46|11.9
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AARP [1000]|AARP [100000]|228||||228|23.47|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|228||||228|16.97|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AETNA [1015]|AETNA [101529]|228||||228|22.99|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|228||||228|14.11|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|228||||228|16.8|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|228||||228|16.8|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BCBS UTHCT [115568]|228||||228|107.16|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|228||||228|25.32|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|228||||228|114|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|228||||228|143.64|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|228||||228|14.11|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|228||||228|16.8|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|CIGNA [1260]|CIGNA GWH [126023]|228||||228|19.54|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|228||||228|157.32|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|228||||228|21|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|228||||228|16.8|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|228||||228|22.99|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|228||||228|14.11|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|228||||228|16.8|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|228||||228|22.99|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|228||||228|14.11|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|228||||228|14.11|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|228||||228|157.32|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|228||||228|14.11|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|Self-pay|Self-pay|228||||228|79.8|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|228||||228|14.11|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|228||||228|14.11|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|228||||228|23.47|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|228||||228|16.8|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|228||||228|16.8|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|228||||228|23.47|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|228||||228|16.8|157.32|14.11
30184443|EAP|0301 - LABORATORY-CHEMISTRY|HC TSH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|228||||228|33.6|157.32|14.11
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AARP [1000]|AARP [100000]|78||||78|71.05|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|78||||78|51.37|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AETNA [1015]|AETNA [101529]|78||||78|69.58|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|78||||78|42.72|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|78||||78|50.86|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|78||||78|50.86|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS [1155]|BCBS UTHCT [115568]|78||||78|36.66|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|78||||78|76.59|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|78||||78|39|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|78||||78|49.14|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|78||||78|42.72|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|78||||78|50.86|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|CIGNA [1260]|CIGNA GWH [126023]|78||||78|59.2|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|78||||78|53.82|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|78||||78|63.58|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|78||||78|50.86|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|78||||78|69.58|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|78||||78|42.72|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|78||||78|50.86|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|78||||78|69.58|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|78||||78|42.72|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|78||||78|42.72|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|78||||78|53.82|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|78||||78|42.72|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|Self-pay|Self-pay|78||||78|27.3|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|78||||78|42.72|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|78||||78|42.72|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|78||||78|71.05|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|78||||78|50.86|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|78||||78|50.86|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|78||||78|71.05|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|78||||78|50.86|101.72|27.3
30184445|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID STIM IMMUNOGLOB (TSI)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|78||||78|101.72|101.72|27.3
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|AARP [1000]|AARP [100000]|31||||31|19.81|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31|14.32|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|AETNA [1015]|AETNA [101529]|31||||31|19.39|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|11.91|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31|14.18|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31|14.18|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|21.36|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|11.91|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31|14.18|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|CIGNA [1260]|CIGNA GWH [126023]|31||||31|16.43|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|17.73|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31|14.18|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|19.39|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|11.91|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31|14.18|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|19.39|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|11.91|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|11.91|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|11.91|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|Self-pay|Self-pay|31||||31|10.85|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|11.91|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|11.91|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31|19.81|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31|14.18|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31|14.18|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31|19.81|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31|14.18|28.36|10.85
30184446|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN E|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31|28.36|28.36|10.85
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AARP [1000]|AARP [100000]|156||||156|7.22|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|156||||156|5.23|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AETNA [1015]|AETNA [101529]|156||||156|7.08|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|156||||156|4.35|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|156||||156|5.18|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|156||||156|5.18|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS [1155]|BCBS UTHCT [115568]|156||||156|73.32|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|156||||156|7.8|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|156||||156|78|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|156||||156|98.28|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|156||||156|4.35|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|156||||156|5.18|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|CIGNA [1260]|CIGNA GWH [126023]|156||||156|5.95|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|156||||156|107.64|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|156||||156|6.48|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|156||||156|5.18|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|156||||156|7.08|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|156||||156|4.35|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|156||||156|5.18|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|156||||156|7.08|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|156||||156|4.35|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|156||||156|4.35|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|156||||156|107.64|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|156||||156|4.35|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|Self-pay|Self-pay|156||||156|54.6|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|156||||156|4.35|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|156||||156|4.35|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|156||||156|7.22|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|156||||156|5.18|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|156||||156|5.18|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|156||||156|7.22|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|156||||156|5.18|107.64|4.35
30184450|EAP|0301 - LABORATORY-CHEMISTRY|HC AST/SGOT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|156||||156|10.36|107.64|4.35
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AARP [1000]|AARP [100000]|126||||126|7.4|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126||||126|5.35|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AETNA [1015]|AETNA [101529]|126||||126|7.25|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126||||126|4.45|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126||||126|5.3|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126||||126|5.3|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS [1155]|BCBS UTHCT [115568]|126||||126|59.22|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126||||126|7.98|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126||||126|63|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126||||126|79.38|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126||||126|4.45|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126||||126|5.3|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|CIGNA [1260]|CIGNA GWH [126023]|126||||126|6.24|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126||||126|86.94|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|126||||126|6.63|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126||||126|5.3|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126||||126|7.25|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126||||126|4.45|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126||||126|5.3|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126||||126|7.25|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126||||126|4.45|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|126||||126|4.45|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126||||126|86.94|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126||||126|4.45|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|Self-pay|Self-pay|126||||126|44.1|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|126||||126|4.45|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126||||126|4.45|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126||||126|7.4|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|126||||126|5.3|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|126||||126|5.3|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126||||126|7.4|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126||||126|5.3|86.94|4.45
30184460|EAP|0301 - LABORATORY-CHEMISTRY|HC ALT/SGPT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126||||126|10.6|86.94|4.45
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AARP [1000]|AARP [100000]|174||||174|17.84|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|174||||174|12.89|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AETNA [1015]|AETNA [101529]|174||||174|17.45|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|174||||174|10.72|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|174||||174|12.76|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|174||||174|12.76|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BCBS UTHCT [115568]|174||||174|81.78|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|174||||174|19.23|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|174||||174|87|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|174||||174|109.62|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|174||||174|10.72|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|174||||174|12.76|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|CIGNA [1260]|CIGNA GWH [126023]|174||||174|14.74|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|174||||174|120.06|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|174||||174|15.95|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|174||||174|12.76|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|174||||174|17.45|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|174||||174|10.72|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|174||||174|12.76|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|174||||174|17.45|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|174||||174|10.72|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|174||||174|10.72|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|174||||174|120.06|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|174||||174|10.72|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|Self-pay|Self-pay|174||||174|60.9|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|174||||174|10.72|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|174||||174|10.72|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|174||||174|17.84|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|174||||174|12.76|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|174||||174|12.76|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|174||||174|17.84|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|174||||174|12.76|120.06|10.72
30184466|EAP|0301 - LABORATORY-CHEMISTRY|HC TRANSFERRIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|174||||174|25.52|120.06|10.72
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AARP [1000]|AARP [100000]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AETNA [1015]|AETNA [101529]|186||||186|7.85|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BCBS UTHCT [115568]|186||||186|87.42|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|186||||186|8.65|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|186||||186|93|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|186||||186|117.18|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|CIGNA [1260]|CIGNA GWH [126023]|186||||186|6.79|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|186||||186|128.34|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|186||||186|7.18|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|186||||186|7.85|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|186||||186|7.85|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|186||||186|128.34|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|Self-pay|Self-pay|186||||186|65.1|128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|186||||186||128.34|6.79
30184478|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIGLYCERIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|186||||186||128.34|6.79
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AARP [1000]|AARP [100000]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AETNA [1015]|AETNA [101529]|177||||177|8.86|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BCBS UTHCT [115568]|177||||177|83.19|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|177||||177|9.74|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|177||||177|88.5|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|177||||177|111.51|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|CIGNA [1260]|CIGNA GWH [126023]|177||||177|7.64|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|177||||177|122.13|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|177||||177|8.09|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|177||||177|8.86|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|177||||177|8.86|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|177||||177|122.13|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|Self-pay|Self-pay|177||||177|61.95|122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|177||||177||122.13|7.64
30184479|EAP|0301 - LABORATORY-CHEMISTRY|HC THYROID HORMONE UPTAKE/RATIO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|177||||177||122.13|7.64
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AARP [1000]|AARP [100000]|179||||179|19.81|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|179||||179|14.32|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AETNA [1015]|AETNA [101529]|179||||179|19.39|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|179||||179|11.91|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|179||||179|14.18|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|179||||179|14.18|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|179||||179|84.13|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|179||||179|21.36|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|179||||179|89.5|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|179||||179|112.77|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|179||||179|11.91|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|179||||179|14.18|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|179||||179|16.43|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|179||||179|123.51|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|179||||179|17.73|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|179||||179|14.18|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|179||||179|19.39|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|179||||179|11.91|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|179||||179|14.18|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|179||||179|19.39|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|179||||179|11.91|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|179||||179|11.91|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|179||||179|123.51|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|179||||179|11.91|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|Self-pay|Self-pay|179||||179|62.65|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|179||||179|11.91|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|179||||179|11.91|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|179||||179|19.81|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|179||||179|14.18|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|179||||179|14.18|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|179||||179|19.81|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|179||||179|14.18|123.51|11.91
30184480|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|179||||179|28.36|123.51|11.91
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AARP [1000]|AARP [100000]|303||||303|23.67|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|303||||303|17.11|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AETNA [1015]|AETNA [101529]|303||||303|23.18|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|303||||303|14.23|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|303||||303|16.94|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|303||||303|16.94|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BCBS UTHCT [115568]|303||||303|142.41|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|303||||303|25.52|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|303||||303|151.5|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|303||||303|190.89|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|303||||303|14.23|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|303||||303|16.94|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|CIGNA [1260]|CIGNA GWH [126023]|303||||303|19.54|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|303||||303|209.07|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|303||||303|21.18|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|303||||303|16.94|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|303||||303|23.18|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|303||||303|14.23|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|303||||303|16.94|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|303||||303|23.18|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|303||||303|14.23|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|303||||303|14.23|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|303||||303|209.07|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|303||||303|14.23|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|Self-pay|Self-pay|303||||303|106.05|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|303||||303|14.23|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|303||||303|14.23|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|303||||303|23.67|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|303||||303|16.94|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|303||||303|16.94|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|303||||303|23.67|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|303||||303|16.94|209.07|14.23
30184481|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|303||||303|33.88|209.07|14.23
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|AARP [1000]|AARP [100000]|389||||389|22.02|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|389||||389|15.92|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|AETNA [1015]|AETNA [101529]|389||||389|21.55|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|389||||389|13.24|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|389||||389|15.76|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|389||||389|15.76|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|BCBS [1155]|BCBS UTHCT [115568]|389||||389|182.83|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|389||||389|23.74|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|389||||389|194.5|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|389||||389|245.07|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|389||||389|13.24|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|389||||389|15.76|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|CIGNA [1260]|CIGNA GWH [126023]|389||||389|18.42|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|389||||389|268.41|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|389||||389|19.7|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|389||||389|15.76|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|389||||389|21.55|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|389||||389|13.24|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|389||||389|15.76|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|389||||389|21.55|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|389||||389|13.24|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|389||||389|13.24|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|389||||389|268.41|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|389||||389|13.24|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|Self-pay|Self-pay|389||||389|136.15|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|389||||389|13.24|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|389||||389|13.24|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|389||||389|22.02|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|389||||389|15.76|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|389||||389|15.76|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|389||||389|22.02|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|389||||389|15.76|268.41|13.24
30184482|EAP|0301 - LABORATORY-CHEMISTRY|HC TRIIODOTHYRONINE (T-3) REVERS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|389||||389|31.52|268.41|13.24
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AARP [1000]|AARP [100000]|259||||259|13.75|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|259||||259|12.59|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AETNA [1015]|AETNA [101529]|259||||259|17.06|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|259||||259|10.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|259||||259|12.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|259||||259|12.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BCBS UTHCT [115568]|259||||259|121.73|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|259||||259|15.21|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|259||||259|129.5|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|259||||259|163.17|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|259||||259|10.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|259||||259|12.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|CIGNA [1260]|CIGNA GWH [126023]|259||||259|11.33|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|259||||259|178.71|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|259||||259|15.59|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|259||||259|12.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|259||||259|17.06|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|259||||259|10.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|259||||259|12.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|259||||259|17.06|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|259||||259|10.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|259||||259|10.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|259||||259|178.71|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|259||||259|10.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|Self-pay|Self-pay|259||||259|90.65|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|259||||259|10.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|259||||259|10.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|259||||259|13.75|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|259||||259|12.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|259||||259|12.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|259||||259|13.75|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|259||||259|12.47|178.71|10.47
30184484|EAP|0301 - LABORATORY-CHEMISTRY|HC TROPONIN QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|259||||259|24.94|178.71|10.47
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AARP [1000]|AARP [100000]|117||||117|5.51|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|117||||117|3.99|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AETNA [1015]|AETNA [101529]|117||||117|5.4|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|117||||117|3.32|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|117||||117|3.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|117||||117|3.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BCBS UTHCT [115568]|117||||117|54.99|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|117||||117|5.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|117||||117|58.5|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|117||||117|73.71|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|117||||117|3.32|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|117||||117|3.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|CIGNA [1260]|CIGNA GWH [126023]|117||||117|4.54|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|117||||117|80.73|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|117||||117|4.94|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|117||||117|3.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|117||||117|5.4|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|117||||117|3.32|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|117||||117|3.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|117||||117|5.4|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|117||||117|3.32|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|117||||117|3.32|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|117||||117|80.73|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|117||||117|3.32|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|Self-pay|Self-pay|117||||117|40.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|117||||117|3.32|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|117||||117|3.32|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|117||||117|5.51|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|117||||117|3.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|117||||117|3.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|117||||117|5.51|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|117||||117|3.95|80.73|3.32
30184520|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN BLD (BUN)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|117||||117|7.9|80.73|3.32
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AARP [1000]|AARP [100000]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AETNA [1015]|AETNA [101529]|17||||17|7.61|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BCBS UTHCT [115568]|17||||17|7.99|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17||||17|7.15|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17||||17|8.5|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17||||17|10.71|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|CIGNA [1260]|CIGNA GWH [126023]|17||||17|5.39|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|17||||17|11.73|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17||||17|6.95|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17||||17|7.61|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17||||17|7.61|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|17||||17|11.73|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|Self-pay|Self-pay|17||||17|5.95|11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17||||17||11.73|5.39
30184540|EAP|0301 - LABORATORY-CHEMISTRY|HC UREA NITROGEN URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17||||17||11.73|5.39
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AARP [1000]|AARP [100000]|97||||97|6.31|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97||||97|4.57|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AETNA [1015]|AETNA [101529]|97||||97|6.19|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97||||97|3.8|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97||||97|4.52|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97||||97|4.52|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BCBS UTHCT [115568]|97||||97|45.59|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97||||97|6.81|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97||||97|48.5|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97||||97|61.11|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97||||97|3.8|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97||||97|4.52|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|CIGNA [1260]|CIGNA GWH [126023]|97||||97|5.39|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97||||97|66.93|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|97||||97|5.65|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97||||97|4.52|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97||||97|6.19|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97||||97|3.8|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97||||97|4.52|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97||||97|6.19|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97||||97|3.8|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|97||||97|3.8|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97||||97|66.93|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97||||97|3.8|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|Self-pay|Self-pay|97||||97|33.95|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|97||||97|3.8|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97||||97|3.8|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97||||97|6.31|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|97||||97|4.52|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|97||||97|4.52|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97||||97|6.31|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97||||97|4.52|66.93|3.8
30184550|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97||||97|9.04|66.93|3.8
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AARP [1000]|AARP [100000]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|109||||109|6.96|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BCBS UTHCT [115568]|109||||109|51.23|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109||||109|7.15|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109||||109|54.5|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109||||109|68.67|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|CIGNA [1260]|CIGNA GWH [126023]|109||||109|5.39|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|109||||109|75.21|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|109||||109|6.35|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109||||109|6.96|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109||||109|6.96|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|109||||109|75.21|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|Self-pay|Self-pay|109||||109|38.15|75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109||||109||75.21|5.39
30184560|EAP|0301 - LABORATORY-CHEMISTRY|HC URIC ACID OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|109||||109||75.21|5.39
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|AARP [1000]|AARP [100000]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|AETNA [1015]|AETNA [101529]|283||||283|21.22|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|BCBS [1155]|BCBS UTHCT [115568]|283||||283|133.01|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|283||||283|23.34|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|283||||283|141.5|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|283||||283|178.29|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|CIGNA [1260]|CIGNA GWH [126023]|283||||283|18.13|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|283||||283|195.27|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|283||||283|19.38|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|283||||283|21.22|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|283||||283|21.22|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|283||||283|195.27|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|Self-pay|Self-pay|283||||283|99.05|195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|283||||283||195.27|18.13
30184585|EAP|0301 - LABORATORY-CHEMISTRY|HC VANILLYMANDELIC ACID(VMA) URINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|283||||283||195.27|18.13
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|AARP [1000]|AARP [100000]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|AETNA [1015]|AETNA [101529]|372||||372|48.34|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|BCBS [1155]|BCBS UTHCT [115568]|372||||372|174.84|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|372||||372|53.22|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|372||||372|186|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|372||||372|234.36|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|CIGNA [1260]|CIGNA GWH [126023]|372||||372|41.06|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|372||||372|256.68|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|372||||372|44.16|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|372||||372|48.34|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|372||||372|48.34|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|372||||372|256.68|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|Self-pay|Self-pay|372||||372|130.2|256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|372||||372||256.68|41.06
30184586|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOACTIVE INTEST PEPTIDE(VIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|372||||372||256.68|41.06
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|AARP [1000]|AARP [100000]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|AETNA [1015]|AETNA [101529]|536||||536|46.44|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|BCBS [1155]|BCBS UTHCT [115568]|536||||536|251.92|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|536||||536|51.12|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|536||||536|268|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|536||||536|337.68|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|CIGNA [1260]|CIGNA GWH [126023]|536||||536|39.37|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|536||||536|369.84|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|536||||536|42.43|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|536||||536|46.44|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|536||||536|46.44|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|536||||536|369.84|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|Self-pay|Self-pay|536||||536|187.6|369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|536||||536||369.84|39.37
30184588|EAP|0301 - LABORATORY-CHEMISTRY|HC VASOPRESSIN (ADH)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|536||||536||369.84|39.37
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AARP [1000]|AARP [100000]|278||||278|16.2|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|278||||278|11.73|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AETNA [1015]|AETNA [101529]|278||||278|15.89|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|278||||278|9.75|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|278||||278|11.61|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|278||||278|11.61|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BCBS UTHCT [115568]|278||||278|130.66|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|278||||278|17.48|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|278||||278|139|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|278||||278|175.14|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|278||||278|9.75|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|278||||278|11.61|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|CIGNA [1260]|CIGNA GWH [126023]|278||||278|13.6|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|278||||278|191.82|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|278||||278|14.51|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|278||||278|11.61|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|278||||278|15.89|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|278||||278|9.75|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|278||||278|11.61|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|278||||278|15.89|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|278||||278|9.75|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|278||||278|9.75|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|278||||278|191.82|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|278||||278|9.75|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|Self-pay|Self-pay|278||||278|97.3|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|278||||278|9.75|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|278||||278|9.75|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|278||||278|16.2|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|278||||278|11.61|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|278||||278|11.61|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|278||||278|16.2|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|278||||278|11.61|191.82|9.75
30184590|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN A (RETINOL)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|278||||278|23.22|191.82|9.75
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|AARP [1000]|AARP [100000]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|AETNA [1015]|AETNA [101529]|140||||140|23.33|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|BCBS [1155]|BCBS UTHCT [115568]|140||||140|65.8|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|140||||140|20.81|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|140||||140|70|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|140||||140|88.2|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|CIGNA [1260]|CIGNA GWH [126023]|140||||140|13.6|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|140||||140|96.6|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|140||||140|21.33|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|140||||140|23.33|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|140||||140|23.33|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|140||||140|96.6|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|Self-pay|Self-pay|140||||140|49|96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|140||||140||96.6|13.6
30184591|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|140||||140||96.6|13.6
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AARP [1000]|AARP [100000]|71||||71|19.15|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71||||71|13.86|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AETNA [1015]|AETNA [101529]|71||||71|18.77|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71||||71|11.52|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71||||71|13.72|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71||||71|13.72|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BCBS UTHCT [115568]|71||||71|33.37|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71||||71|20.67|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71||||71|35.5|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71||||71|44.73|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71||||71|11.52|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71||||71|13.72|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|CIGNA [1260]|CIGNA GWH [126023]|71||||71|15.86|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71||||71|48.99|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71||||71|17.15|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71||||71|13.72|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71||||71|18.77|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71||||71|11.52|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71||||71|13.72|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71||||71|18.77|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71||||71|11.52|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|71||||71|11.52|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71||||71|48.99|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71||||71|11.52|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|Self-pay|Self-pay|71||||71|24.85|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71||||71|11.52|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71||||71|11.52|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71||||71|19.15|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71||||71|13.72|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71||||71|13.72|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71||||71|19.15|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71||||71|13.72|48.99|11.52
30184597|EAP|0301 - LABORATORY-CHEMISTRY|HC VITAMIN K|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71||||71|27.44|48.99|11.52
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AARP [1000]|AARP [100000]|110||||110|15.91|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|110||||110|11.5|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AETNA [1015]|AETNA [101529]|110||||110|15.58|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|110||||110|9.57|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|110||||110|11.39|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|110||||110|11.39|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS [1155]|BCBS UTHCT [115568]|110||||110|51.7|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|110||||110|17.15|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|110||||110|55|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|110||||110|69.3|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|110||||110|9.57|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|110||||110|11.39|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|CIGNA [1260]|CIGNA GWH [126023]|110||||110|13.32|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|110||||110|75.9|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|110||||110|14.24|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|110||||110|11.39|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|110||||110|15.58|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|110||||110|9.57|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|110||||110|11.39|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|110||||110|15.58|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|110||||110|9.57|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|110||||110|9.57|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|110||||110|75.9|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|110||||110|9.57|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|Self-pay|Self-pay|110||||110|38.5|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|110||||110|9.57|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|110||||110|9.57|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|110||||110|15.91|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|110||||110|11.39|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|110||||110|11.39|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|110||||110|15.91|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|110||||110|11.39|75.9|9.57
30184630|EAP|0301 - LABORATORY-CHEMISTRY|HC ZINC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|110||||110|22.78|75.9|9.57
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|AARP [1000]|AARP [100000]|184||||184|29.07|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184||||184|21.02|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|AETNA [1015]|AETNA [101529]|184||||184|28.46|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184||||184|17.48|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184||||184|20.81|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184||||184|20.81|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|BCBS [1155]|BCBS UTHCT [115568]|184||||184|86.48|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184||||184|31.35|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184||||184|92|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184||||184|115.92|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184||||184|17.48|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184||||184|20.81|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|CIGNA [1260]|CIGNA GWH [126023]|184||||184|24.07|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|184||||184|126.96|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|184||||184|26.01|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184||||184|20.81|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184||||184|28.46|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184||||184|17.48|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184||||184|20.81|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184||||184|28.46|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184||||184|17.48|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|184||||184|17.48|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|184||||184|126.96|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184||||184|17.48|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|Self-pay|Self-pay|184||||184|64.4|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|184||||184|17.48|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184||||184|17.48|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184||||184|29.07|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|184||||184|20.81|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|184||||184|20.81|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184||||184|29.07|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184||||184|20.81|126.96|17.48
30184681|EAP|0301 - LABORATORY-CHEMISTRY|HC C-PEPTIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184||||184|41.62|126.96|17.48
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|AARP [1000]|AARP [100000]|311||||311|21.03|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|311||||311|15.2|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|AETNA [1015]|AETNA [101529]|311||||311|20.59|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|311||||311|12.64|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|311||||311|15.05|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|311||||311|15.05|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|BCBS [1155]|BCBS UTHCT [115568]|311||||311|146.17|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|311||||311|22.68|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|311||||311|155.5|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|311||||311|195.93|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|311||||311|12.64|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|311||||311|15.05|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|CIGNA [1260]|CIGNA GWH [126023]|311||||311|17.57|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|311||||311|214.59|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|311||||311|18.81|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|311||||311|15.05|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|311||||311|20.59|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|311||||311|12.64|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|311||||311|15.05|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|311||||311|20.59|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|311||||311|12.64|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|311||||311|12.64|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|311||||311|214.59|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|311||||311|12.64|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|Self-pay|Self-pay|311||||311|108.85|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|311||||311|12.64|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|311||||311|12.64|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|311||||311|21.03|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|311||||311|15.05|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|311||||311|15.05|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|311||||311|21.03|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|311||||311|15.05|214.59|12.64
30184702|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|311||||311|30.1|214.59|12.64
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AARP [1000]|AARP [100000]|144||||144|10.49|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|144||||144|7.6|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AETNA [1015]|AETNA [101529]|144||||144|10.3|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|144||||144|6.32|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|144||||144|7.52|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|144||||144|7.52|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BCBS UTHCT [115568]|144||||144|67.68|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|144||||144|11.33|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|144||||144|72|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|144||||144|90.72|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|144||||144|6.32|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|144||||144|7.52|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|CIGNA [1260]|CIGNA GWH [126023]|144||||144|14.05|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|144||||144|99.36|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|144||||144|9.4|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|144||||144|7.52|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|144||||144|10.3|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|144||||144|6.32|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|144||||144|7.52|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|144||||144|10.3|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|144||||144|6.32|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|144||||144|6.32|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|144||||144|99.36|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|144||||144|6.32|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|Self-pay|Self-pay|144||||144|50.4|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|144||||144|6.32|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|144||||144|6.32|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|144||||144|10.49|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|144||||144|7.52|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|144||||144|7.52|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|144||||144|10.49|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|144||||144|7.52|99.36|6.32
30184703|EAP|0301 - LABORATORY-CHEMISTRY|HC HCG QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|144||||144|15.04|99.36|6.32
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AARP [1000]|AARP [100000]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AETNA [1015]|AETNA [101529]|184||||184|81.14|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184||||184|54.56|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BCBS UTHCT [115568]|184||||184|86.48|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184||||184|0|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184||||184|92|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184||||184|115.92|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184||||184|54.56|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|CIGNA [1260]|CIGNA GWH [126023]|184||||184|0|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|184||||184|126.96|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|184||||184|92|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184||||184|81.14|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184||||184|54.56|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184||||184|81.14|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184||||184|54.56|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|184||||184|54.56|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|184||||184|126.96|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184||||184|54.56|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|Self-pay|Self-pay|184||||184|64.4|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|184||||184|54.56|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184||||184|54.56|126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184||||184||126.96|54.56
30184999|EAP|0301 - LABORATORY-CHEMISTRY|HC UNLISTED CHEMISTRY TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184||||184||126.96|54.56
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|AARP [1000]|AARP [100000]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|AETNA [1015]|AETNA [101529]|108||||108|48.89|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|BCBS [1155]|BCBS UTHCT [115568]|108||||108|50.76|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108||||108|43.6|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108||||108|54|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108||||108|68.04|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|CIGNA [1260]|CIGNA GWH [126023]|108||||108|31.16|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|108||||108|74.52|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|108||||108|44.68|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108||||108|48.89|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108||||108|48.89|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|108||||108|74.52|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|Self-pay|Self-pay|108||||108|37.8|74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108||||108||74.52|31.16
30185055|EAP|0305 - LABORATORY-HEMATOLOGY|HC RETICULATED PLATELET ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108||||108||74.52|31.16
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|AARP [1000]|AARP [100000]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|AETNA [1015]|AETNA [101529]|183||||183|24.6|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|BCBS [1155]|BCBS UTHCT [115568]|183||||183|86.01|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|183||||183|27.07|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|183||||183|91.5|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|183||||183|115.29|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|CIGNA [1260]|CIGNA GWH [126023]|183||||183|100.65|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|183||||183|126.27|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|183||||183|22.48|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|183||||183|24.6|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|183||||183|24.6|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|183||||183|126.27|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|Self-pay|Self-pay|183||||183|64.05|126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|183||||183||126.27|22.48
30185598|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEXAGONAL PHOSPHOLIPID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|183||||183||126.27|22.48
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|AARP [1000]|AARP [100000]|31.96||||31.96|7.3|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.96||||31.96|7.9|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|AETNA [1015]|AETNA [101529]|31.96||||31.96|10.7|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.96||||31.96|6.57|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.96||||31.96|7.82|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.96||||31.96|7.82|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|BCBS [1155]|BCBS UTHCT [115568]|31.96||||31.96|15.02|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.96||||31.96|9.54|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.96||||31.96|15.98|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.96||||31.96|20.13|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.96||||31.96|6.57|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.96||||31.96|7.82|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|CIGNA [1260]|CIGNA GWH [126023]|31.96||||31.96|5.95|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31.96||||31.96|22.05|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.96||||31.96|9.78|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.96||||31.96|7.82|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.96||||31.96|10.7|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.96||||31.96|6.57|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.96||||31.96|7.82|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.96||||31.96|10.7|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.96||||31.96|6.57|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.96||||31.96|6.57|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31.96||||31.96|22.05|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.96||||31.96|6.57|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|Self-pay|Self-pay|31.96||||31.96|11.19|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.96||||31.96|6.57|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.96||||31.96|6.57|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.96||||31.96|7.3|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.96||||31.96|7.82|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.96||||31.96|7.82|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.96||||31.96|7.3|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.96||||31.96|7.82|22.05|5.95
30186001|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGG EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.96||||31.96|15.64|22.05|5.95
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|AARP [1000]|AARP [100000]|134||||134|7.3|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|134||||134|5.27|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|AETNA [1015]|AETNA [101529]|134||||134|7.15|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|134||||134|4.38|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|134||||134|5.22|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|134||||134|5.22|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|BCBS [1155]|BCBS UTHCT [115568]|134||||134|62.98|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|134||||134|7.86|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|134||||134|67|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|134||||134|84.42|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|134||||134|4.38|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|134||||134|5.22|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|CIGNA [1260]|CIGNA GWH [126023]|134||||134|5.95|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|134||||134|92.46|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|134||||134|6.53|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|134||||134|5.22|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|134||||134|7.15|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|134||||134|4.38|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|134||||134|5.22|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|134||||134|7.15|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|134||||134|4.38|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|134||||134|4.38|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|134||||134|92.46|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|134||||134|4.38|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|Self-pay|Self-pay|134||||134|46.9|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|134||||134|4.38|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|134||||134|4.38|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|134||||134|7.3|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|134||||134|5.22|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|134||||134|5.22|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|134||||134|7.3|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|134||||134|5.22|92.46|4.38
30186003|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE CRUDE ALLERGEN EXTRACT EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|134||||134|10.44|92.46|4.38
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|AARP [1000]|AARP [100000]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|AETNA [1015]|AETNA [101529]|35||||35|10.9|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|35||||35|16.45|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35||||35|12|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35||||35|17.5|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35||||35|22.05|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|35||||35|9.35|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|35||||35|24.15|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35||||35|9.96|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35||||35|10.9|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35||||35|10.9|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|35||||35|24.15|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|Self-pay|Self-pay|35||||35|12.25|24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35||||35||24.15|9.35
30186005|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLERGEN SPEC IGE QL MULTI SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35||||35||24.15|9.35
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AARP [1000]|AARP [100000]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AETNA [1015]|AETNA [101529]|672||||672|25.13|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BCBS UTHCT [115568]|672||||672|315.84|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|672||||672|27.67|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|672||||672|336|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|672||||672|423.36|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|CIGNA [1260]|CIGNA GWH [126023]|672||||672|21.24|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|GROUP PENSION ADMIN [1450]|GPA [145000]|672||||672|463.68|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|672||||672|22.96|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|672||||672|25.13|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|672||||672|25.13|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|PHCS [1780]|PHCS MULTIPLAN [178000]|672||||672|463.68|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|Self-pay|Self-pay|672||||672|235.2|463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|672||||672||463.68|21.24
30186022|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|672||||672||463.68|21.24
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|AARP [1000]|AARP [100000]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|AETNA [1015]|AETNA [101529]|1202||||1202|17.04|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|BCBS [1155]|BCBS UTHCT [115568]|1202||||1202|564.94|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1202||||1202|18.76|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1202||||1202|601|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1202||||1202|757.26|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|CIGNA [1260]|CIGNA GWH [126023]|1202||||1202|14.45|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1202||||1202|829.38|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1202||||1202|15.58|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1202||||1202|17.04|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1202||||1202|17.04|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1202||||1202|829.38|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|Self-pay|Self-pay|1202||||1202|420.7|829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1202||||1202||829.38|14.45
30186023|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ID PLATELET IMMUNOGL ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1202||||1202||829.38|14.45
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AARP [1000]|AARP [100000]|414||||414|16.89|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|414||||414|12.21|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AETNA [1015]|AETNA [101529]|414||||414|16.54|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|414||||414|10.16|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|414||||414|12.09|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|414||||414|12.09|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BCBS UTHCT [115568]|414||||414|194.58|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|414||||414|18.2|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|414||||414|207|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|414||||414|260.82|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|414||||414|10.16|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|414||||414|12.09|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|CIGNA [1260]|CIGNA GWH [126023]|414||||414|14.17|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|414||||414|285.66|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|414||||414|15.11|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|414||||414|12.09|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|414||||414|16.54|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|414||||414|10.16|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|414||||414|12.09|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|414||||414|16.54|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|414||||414|10.16|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|414||||414|10.16|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|414||||414|285.66|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|414||||414|10.16|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|Self-pay|Self-pay|414||||414|144.9|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|414||||414|10.16|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|414||||414|10.16|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|414||||414|16.89|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|414||||414|12.09|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|414||||414|12.09|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|414||||414|16.89|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|414||||414|12.09|285.66|10.16
30186038|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|414||||414|24.18|285.66|10.16
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AARP [1000]|AARP [100000]|116||||116|6.61|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116|4.77|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AETNA [1015]|AETNA [101529]|116||||116|6.46|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116|34.39|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116|4.72|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116|4.72|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|7.11|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116|34.39|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116|4.72|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|5.39|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|5.9|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116|4.72|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|6.46|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116|34.39|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116|4.72|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|6.46|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116|34.39|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116|34.39|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116|34.39|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|Self-pay|Self-pay|116||||116|40.6|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116|34.39|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116|34.39|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116|6.61|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116|4.72|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116|4.72|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116|6.61|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116|4.72|80.04|4.72
30189050|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116|9.44|80.04|4.72
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AARP [1000]|AARP [100000]|116||||116|7.7|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116|5.66|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AETNA [1015]|AETNA [101529]|116||||116|7.66|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116|34.39|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116|5.6|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116|5.6|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|8.3|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116|34.39|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116|5.6|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|6.5|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|7|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116|5.6|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|7.66|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116|34.39|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116|5.6|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|7.66|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116|34.39|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116|34.39|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116|34.39|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|Self-pay|Self-pay|116||||116|40.6|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116|34.39|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116|34.39|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116|7.7|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116|5.6|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116|5.6|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116|7.7|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116|5.6|80.04|5.6
30189051|EAP|0309 - LABORATORY-OTHER LABORATORY|HC CELL CNT BODY FLUID W/DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116|11.2|80.04|5.6
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AARP [1000]|AARP [100000]|73||||73|5.96|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|73||||73|4.31|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AETNA [1015]|AETNA [101529]|73||||73|5.83|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|73||||73|21.64|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|73||||73|4.27|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|73||||73|4.27|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BCBS UTHCT [115568]|73||||73|34.31|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|73||||73|6.43|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|73||||73|36.5|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|73||||73|45.99|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|73||||73|21.64|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|73||||73|4.27|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|CIGNA [1260]|CIGNA GWH [126023]|73||||73|4.81|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|73||||73|50.37|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|73||||73|5.34|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|73||||73|4.27|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|73||||73|5.83|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|73||||73|21.64|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|73||||73|4.27|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|73||||73|5.83|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|73||||73|21.64|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|73||||73|21.64|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|73||||73|50.37|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|73||||73|21.64|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|Self-pay|Self-pay|73||||73|25.55|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|73||||73|21.64|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|73||||73|21.64|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|73||||73|5.96|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|73||||73|4.27|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|73||||73|4.27|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|73||||73|5.96|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|73||||73|4.27|50.37|4.27
30189055|EAP|0309 - LABORATORY-OTHER LABORATORY|HC LEUKOCYT ASSESS WBC FECAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|73||||73|8.54|50.37|4.27
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AARP [1000]|AARP [100000]|116||||116|9.99|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116|7.4|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AETNA [1015]|AETNA [101529]|116||||116|10.03|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116|34.39|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116|7.33|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116|7.33|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|10.77|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116|34.39|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116|7.33|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|34.57|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|9.16|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116|7.33|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|10.03|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116|34.39|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116|7.33|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|10.03|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116|34.39|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116|34.39|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116|34.39|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|Self-pay|Self-pay|116||||116|40.6|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116|34.39|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116|34.39|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116|9.99|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116|7.33|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116|7.33|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116|9.99|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116|7.33|80.04|7.33
30189060|EAP|0300 - LABORATORY-GENERAL|HC CRYSTAL ID LIGHT MICROSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116|14.66|80.04|7.33
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AARP [1000]|AARP [100000]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AETNA [1015]|AETNA [101529]|109||||109|7.92|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|109||||109|32.32|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BCBS UTHCT [115568]|109||||109|51.23|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|109||||109|7.15|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|109||||109|54.5|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|109||||109|68.67|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|109||||109|32.32|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|CIGNA [1260]|CIGNA GWH [126023]|109||||109|5.39|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|109||||109|75.21|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|109||||109|7.24|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|109||||109|7.92|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|109||||109|32.32|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|109||||109|7.92|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|109||||109|32.32|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|109||||109|32.32|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|109||||109|75.21|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|109||||109|32.32|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|Self-pay|Self-pay|109||||109|38.15|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|109||||109|32.32|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|109||||109|32.32|75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|109||||109||75.21|5.39
30189190|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SMEAR NASAL EOSINOPHILS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|109||||109||75.21|5.39
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AARP [1000]|AARP [100000]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AETNA [1015]|AETNA [101529]|432||||432|22.99|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|432||||432|128.09|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS [1155]|BCBS UTHCT [115568]|432||||432|203.04|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|432||||432|157.6|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|432||||432|216|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|432||||432|272.16|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|432||||432|128.09|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|CIGNA [1260]|CIGNA GWH [126023]|432||||432|11.93|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|432||||432|298.08|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|432||||432|186.45|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|432||||432|22.99|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|432||||432|128.09|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|432||||432|22.99|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|432||||432|128.09|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|432||||432|128.09|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|432||||432|298.08|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|432||||432|128.09|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|Self-pay|Self-pay|432||||432|151.2|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|432||||432|128.09|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|432||||432|128.09|298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|432||||432||298.08|11.93
30189220|EAP|0309 - LABORATORY-OTHER LABORATORY|HC SPUTUM COLLECTN AEROSL INDUCD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|432||||432||298.08|11.93
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.18||||0.18|0.08|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.18||||0.18|0.05|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.18||||0.18|0.08|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.18||||0.18|0.09|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.18||||0.18|0.09|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.18||||0.18|0.11|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.18||||0.18|0.05|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.18||||0.18|0.1|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.18||||0.18|0.12|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.18||||0.18|0.09|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.18||||0.18|0.08|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.18||||0.18|0.05|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.18||||0.18|0.08|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.18||||0.18|0.05|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.18||||0.18|0.05|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.18||||0.18|0.12|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.18||||0.18|0.05|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.18||||0.18|0.06|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.18||||0.18|0.05|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.18||||0.18|0.05|0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.18||||0.18||0.12|0.05
30264|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CITALOPRAM 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.18||||0.18||0.12|0.05
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|AARP [1000]|AARP [100000]|127||||127|22.14|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|127||||127|18.11|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|AETNA [1015]|AETNA [101529]|127||||127|24.53|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|127||||127|15.06|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|127||||127|17.93|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|127||||127|17.93|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|BCBS [1155]|BCBS UTHCT [115568]|127||||127|59.69|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|127||||127|27.01|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|127||||127|63.5|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|127||||127|80.01|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|127||||127|15.06|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|127||||127|17.93|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|CIGNA [1260]|CIGNA GWH [126023]|127||||127|69.85|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|127||||127|87.63|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|127||||127|22.41|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|127||||127|17.93|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|127||||127|24.53|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|127||||127|15.06|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|127||||127|17.93|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|127||||127|24.53|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|127||||127|15.06|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|127||||127|15.06|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|127||||127|87.63|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|127||||127|15.06|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|Self-pay|Self-pay|127||||127|44.45|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|127||||127|15.06|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|127||||127|15.06|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|127||||127|22.14|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|127||||127|17.93|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|127||||127|17.93|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|127||||127|22.14|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|127||||127|17.93|87.63|15.06
30286008|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ALLG SPEC IGE RECOMB/PURIFIED EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|127||||127|35.86|87.63|15.06
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|AARP [1000]|AARP [100000]|195||||195|15.6|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|195||||195|11.27|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|AETNA [1015]|AETNA [101529]|195||||195|15.26|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|195||||195|9.37|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|195||||195|11.16|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|195||||195|11.16|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|BCBS [1155]|BCBS UTHCT [115568]|195||||195|91.65|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|195||||195|16.81|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|195||||195|97.5|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|195||||195|122.85|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|195||||195|9.37|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|195||||195|11.16|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|CIGNA [1260]|CIGNA GWH [126023]|195||||195|13.03|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|195||||195|134.55|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|195||||195|13.95|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|195||||195|11.16|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|195||||195|15.26|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|195||||195|9.37|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|195||||195|11.16|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|195||||195|15.26|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|195||||195|9.37|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|195||||195|9.37|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|195||||195|134.55|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|195||||195|9.37|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|Self-pay|Self-pay|195||||195|68.25|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|195||||195|9.37|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|195||||195|9.37|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|195||||195|15.6|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|195||||195|11.16|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|195||||195|11.16|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|195||||195|15.6|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|195||||195|11.16|134.55|9.37
30286039|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTINUCLEAR AB (ANA)TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|195||||195|22.32|134.55|9.37
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AARP [1000]|AARP [100000]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AETNA [1015]|AETNA [101529]|92||||92|9.98|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS [1155]|BCBS UTHCT [115568]|92||||92|43.24|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92||||92|10.99|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92||||92|46|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92||||92|57.96|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|CIGNA [1260]|CIGNA GWH [126023]|92||||92|8.5|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|92||||92|63.48|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|92||||92|9.13|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92||||92|9.98|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92||||92|9.98|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|92||||92|63.48|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|Self-pay|Self-pay|92||||92|32.2|63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92||||92||63.48|8.5
30286060|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTISTREPTOLYSIN O TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92||||92||63.48|8.5
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AARP [1000]|AARP [100000]|111||||111|7.23|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111||||111|5.23|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AETNA [1015]|AETNA [101529]|111||||111|7.08|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111||||111|4.35|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111||||111|5.18|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111||||111|5.18|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BCBS UTHCT [115568]|111||||111|52.17|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111||||111|7.8|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111||||111|55.5|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111||||111|69.93|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111||||111|4.35|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111||||111|5.18|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|CIGNA [1260]|CIGNA GWH [126023]|111||||111|5.95|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|111||||111|76.59|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|111||||111|6.48|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111||||111|5.18|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111||||111|7.08|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111||||111|4.35|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111||||111|5.18|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111||||111|7.08|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111||||111|4.35|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|111||||111|4.35|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|111||||111|76.59|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111||||111|4.35|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|Self-pay|Self-pay|111||||111|38.85|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|111||||111|4.35|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111||||111|4.35|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111||||111|7.23|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|111||||111|5.18|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|111||||111|5.18|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111||||111|7.23|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111||||111|5.18|76.59|4.35
30286140|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111||||111|10.36|76.59|4.35
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AARP [1000]|AARP [100000]|116||||116|18.09|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116|13.08|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AETNA [1015]|AETNA [101529]|116||||116|17.71|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116|10.88|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116|12.95|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116|12.95|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|19.5|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116|10.88|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116|12.95|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|15.02|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|16.19|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116|12.95|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|17.71|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116|10.88|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116|12.95|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|17.71|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116|10.88|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116|10.88|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116|10.88|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|Self-pay|Self-pay|116||||116|40.6|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116|10.88|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116|10.88|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116|18.09|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116|12.95|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116|12.95|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116|18.09|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116|12.95|80.04|10.88
30286141|EAP|0302 - LABORATORY-IMMUNOLOGY|HC C-REACTIVE PROTEIN HI SENSITV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116|25.9|80.04|10.88
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AARP [1000]|AARP [100000]|37||||37|35.54|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37||||37|25.7|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AETNA [1015]|AETNA [101529]|37||||37|34.82|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37||||37|21.38|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37||||37|25.45|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37||||37|25.45|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS [1155]|BCBS UTHCT [115568]|37||||37|17.39|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37||||37|37|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37||||37|18.5|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37||||37|23.31|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37||||37|21.38|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37||||37|25.45|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|CIGNA [1260]|CIGNA GWH [126023]|37||||37|29.46|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|37||||37|25.53|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|37||||37|31.81|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37||||37|25.45|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37||||37|34.82|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37||||37|21.38|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37||||37|25.45|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37||||37|34.82|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37||||37|21.38|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|37||||37|21.38|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|37||||37|25.53|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37||||37|21.38|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|Self-pay|Self-pay|37||||37|12.95|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|37||||37|21.38|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37||||37|21.38|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37||||37|35.54|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|37||||37|25.45|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|37||||37|25.45|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37||||37|35.54|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37||||37|25.45|50.9|12.95
30286146|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BETA 2 GLYCOPROTEIN I AB EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37||||37|50.9|50.9|12.95
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AARP [1000]|AARP [100000]|162||||162|35.54|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|162||||162|25.7|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AETNA [1015]|AETNA [101529]|162||||162|34.82|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|162||||162|21.38|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|162||||162|25.45|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|162||||162|25.45|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BCBS UTHCT [115568]|162||||162|76.14|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|162||||162|38.33|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|162||||162|81|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|162||||162|102.06|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|162||||162|21.38|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|162||||162|25.45|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|CIGNA [1260]|CIGNA GWH [126023]|162||||162|29.46|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|162||||162|111.78|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|162||||162|31.81|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|162||||162|25.45|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|162||||162|34.82|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|162||||162|21.38|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|162||||162|25.45|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|162||||162|34.82|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|162||||162|21.38|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|162||||162|21.38|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|162||||162|111.78|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|162||||162|21.38|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|Self-pay|Self-pay|162||||162|56.7|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|162||||162|21.38|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|162||||162|21.38|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|162||||162|35.54|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|162||||162|25.45|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|162||||162|25.45|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|162||||162|35.54|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|162||||162|25.45|111.78|21.38
30286147|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CARDIOLIPIN IG CLASS EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|162||||162|50.9|111.78|21.38
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|AARP [1000]|AARP [100000]|112||||112|22.44|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|112||||112|16.23|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|AETNA [1015]|AETNA [101529]|112||||112|21.98|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|112||||112|13.5|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|112||||112|16.07|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|112||||112|16.07|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|BCBS [1155]|BCBS UTHCT [115568]|112||||112|52.64|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|112||||112|24.2|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|112||||112|56|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|112||||112|70.56|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|112||||112|13.5|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|112||||112|16.07|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|CIGNA [1260]|CIGNA GWH [126023]|112||||112|18.7|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|112||||112|77.28|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|112||||112|20.09|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|112||||112|16.07|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|112||||112|21.98|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|112||||112|13.5|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|112||||112|16.07|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|112||||112|21.98|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|112||||112|13.5|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|112||||112|13.5|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|112||||112|77.28|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|112||||112|13.5|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|Self-pay|Self-pay|112||||112|39.2|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|112||||112|13.5|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|112||||112|13.5|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|112||||112|22.44|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|112||||112|16.07|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|112||||112|16.07|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|112||||112|22.44|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|112||||112|16.07|77.28|13.5
30286148|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTI-PHOSPHATIDYLSERINE ANTIBODY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|112||||112|32.14|77.28|13.5
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|AARP [1000]|AARP [100000]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|AETNA [1015]|AETNA [101529]|23||||23|11.02|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|BCBS [1155]|BCBS UTHCT [115568]|23||||23|10.81|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23||||23|12.14|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23||||23|11.5|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23||||23|14.49|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|CIGNA [1260]|CIGNA GWH [126023]|23||||23|9.35|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23||||23|15.87|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23||||23|10.08|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23||||23|11.02|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23||||23|11.02|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23||||23|15.87|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|Self-pay|Self-pay|23||||23|8.05|15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23||||23||15.87|8.05
30286157|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COLD AGGLUTININ TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23||||23||15.87|8.05
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AARP [1000]|AARP [100000]|234||||234|16.78|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|234||||234|12.12|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AETNA [1015]|AETNA [101529]|234||||234|16.42|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|234||||234|10.08|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|234||||234|12|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|234||||234|12|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS [1155]|BCBS UTHCT [115568]|234||||234|109.98|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|234||||234|18.07|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|234||||234|117|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|234||||234|147.42|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|234||||234|10.08|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|234||||234|12|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|CIGNA [1260]|CIGNA GWH [126023]|234||||234|13.88|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|234||||234|161.46|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|234||||234|15|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|234||||234|12|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|234||||234|16.42|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|234||||234|10.08|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|234||||234|12|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|234||||234|16.42|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|234||||234|10.08|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|234||||234|10.08|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|234||||234|161.46|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|234||||234|10.08|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|Self-pay|Self-pay|234||||234|81.9|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|234||||234|10.08|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|234||||234|10.08|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|234||||234|16.78|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|234||||234|12|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|234||||234|12|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|234||||234|16.78|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|234||||234|12|161.46|10.08
30286160|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT AG EACH COMPONENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|234||||234|24|161.46|10.08
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AARP [1000]|AARP [100000]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AETNA [1015]|AETNA [101529]|306||||306|16.42|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS [1155]|BCBS UTHCT [115568]|306||||306|143.82|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|306||||306|18.07|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|306||||306|153|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|306||||306|192.78|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|CIGNA [1260]|CIGNA GWH [126023]|306||||306|13.88|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|306||||306|211.14|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|306||||306|15|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|306||||306|16.42|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|306||||306|16.42|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|306||||306|211.14|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|Self-pay|Self-pay|306||||306|107.1|211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|306||||306||211.14|13.88
30286161|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT FUNCTIONL ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|306||||306||211.14|13.88
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|AARP [1000]|AARP [100000]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|AETNA [1015]|AETNA [101529]|45.9||||45.9|27.79|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|BCBS [1155]|BCBS UTHCT [115568]|45.9||||45.9|21.57|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45.9||||45.9|30.61|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45.9||||45.9|22.95|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45.9||||45.9|28.92|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|CIGNA [1260]|CIGNA GWH [126023]|45.9||||45.9|23.52|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|GROUP PENSION ADMIN [1450]|GPA [145000]|45.9||||45.9|31.67|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|45.9||||45.9|25.4|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45.9||||45.9|27.79|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45.9||||45.9|27.79|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|PHCS [1780]|PHCS MULTIPLAN [178000]|45.9||||45.9|31.67|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|Self-pay|Self-pay|45.9||||45.9|16.06|31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45.9||||45.9||31.67|16.06
30286162|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPLEMENT CH50|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45.9||||45.9||31.67|16.06
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AARP [1000]|AARP [100000]|189||||189|18.09|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189|13.08|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AETNA [1015]|AETNA [101529]|189||||189|17.71|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189|10.88|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189|12.95|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189|12.95|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|19.5|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189|10.88|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189|12.95|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|15.02|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|16.19|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189|12.95|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|17.71|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189|10.88|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189|12.95|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|17.71|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189|10.88|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189|10.88|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189|10.88|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|Self-pay|Self-pay|189||||189|66.15|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189|10.88|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189|10.88|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189|18.09|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189|12.95|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189|12.95|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189|18.09|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189|12.95|130.41|10.88
30286200|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CCP ANTIBODY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189|25.9|130.41|10.88
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|AARP [1000]|AARP [100000]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|AETNA [1015]|AETNA [101529]|54||||54|18.12|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|BCBS [1155]|BCBS UTHCT [115568]|54||||54|25.38|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54||||54|19.95|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54||||54|27|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54||||54|34.02|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|CIGNA [1260]|CIGNA GWH [126023]|54||||54|15.29|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54||||54|37.26|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54||||54|16.56|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54||||54|18.12|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54||||54|18.12|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54||||54|37.26|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|Self-pay|Self-pay|54||||54|18.9|37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54||||54||37.26|15.29
30286215|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DEOXYRIBONUCLEASE (DNA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54||||54||37.26|15.29
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AARP [1000]|AARP [100000]|27||||27|19.2|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27||||27|13.88|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AETNA [1015]|AETNA [101529]|27||||27|18.79|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27||||27|11.54|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27||||27|13.74|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27||||27|13.74|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS [1155]|BCBS UTHCT [115568]|27||||27|12.69|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27||||27|20.7|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27||||27|13.5|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27||||27|17.01|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27||||27|11.54|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27||||27|13.74|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|CIGNA [1260]|CIGNA GWH [126023]|27||||27|15.86|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|27||||27|18.63|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27||||27|17.18|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27||||27|13.74|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27||||27|18.79|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27||||27|11.54|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27||||27|13.74|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27||||27|18.79|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27||||27|11.54|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|27||||27|11.54|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|27||||27|18.63|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27||||27|11.54|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|Self-pay|Self-pay|27||||27|9.45|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27||||27|11.54|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27||||27|11.54|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27||||27|19.2|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27||||27|13.74|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27||||27|13.74|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27||||27|19.2|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27||||27|13.74|27.48|9.45
30286225|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB DNA NATIVE/DOUBLE STRAND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27||||27|27.48|27.48|9.45
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AARP [1000]|AARP [100000]|252||||252|25.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|252||||252|18.11|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AETNA [1015]|AETNA [101529]|252||||252|24.53|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|252||||252|15.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|252||||252|17.93|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|252||||252|17.93|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS [1155]|BCBS UTHCT [115568]|252||||252|118.44|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|252||||252|27.01|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|252||||252|126|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|252||||252|158.76|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|252||||252|15.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|252||||252|17.93|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|CIGNA [1260]|CIGNA GWH [126023]|252||||252|20.96|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|252||||252|173.88|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|252||||252|22.41|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|252||||252|17.93|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|252||||252|24.53|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|252||||252|15.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|252||||252|17.93|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|252||||252|24.53|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|252||||252|15.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|252||||252|15.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|252||||252|173.88|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|252||||252|15.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|Self-pay|Self-pay|252||||252|88.2|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|252||||252|15.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|252||||252|15.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|252||||252|25.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|252||||252|17.93|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|252||||252|17.93|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|252||||252|25.06|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|252||||252|17.93|173.88|15.06
30286235|EAP|0302 - LABORATORY-IMMUNOLOGY|HC EXTRACTABLE NUCLEAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|252||||252|35.86|173.88|15.06
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AARP [1000]|AARP [100000]|540||||540|16.84|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|540||||540|12.17|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AETNA [1015]|AETNA [101529]|540||||540|16.49|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|540||||540|10.12|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|540||||540|12.05|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|540||||540|12.05|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|540||||540|253.8|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|540||||540|18.15|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|540||||540|270|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|540||||540|340.2|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|540||||540|10.12|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|540||||540|12.05|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|540||||540|26.99|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|540||||540|372.6|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|540||||540|15.06|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|540||||540|12.05|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|540||||540|16.49|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|540||||540|10.12|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|540||||540|12.05|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|540||||540|16.49|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|540||||540|10.12|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|540||||540|10.12|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|540||||540|372.6|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|540||||540|10.12|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|Self-pay|Self-pay|540||||540|189|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|540||||540|10.12|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|540||||540|10.12|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|540||||540|16.84|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|540||||540|12.05|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|540||||540|12.05|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|540||||540|16.84|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|540||||540|12.05|372.6|10.12
30286255|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|540||||540|24.1|372.6|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AARP [1000]|AARP [100000]|304||||304|16.84|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|304||||304|12.17|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AETNA [1015]|AETNA [101529]|304||||304|16.49|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|304||||304|10.12|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|304||||304|12.05|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|304||||304|12.05|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BCBS UTHCT [115568]|304||||304|142.88|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|304||||304|18.15|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|304||||304|152|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|304||||304|191.52|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|304||||304|10.12|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|304||||304|12.05|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|CIGNA [1260]|CIGNA GWH [126023]|304||||304|27.28|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|304||||304|209.76|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|304||||304|15.06|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|304||||304|12.05|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|304||||304|16.49|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|304||||304|10.12|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|304||||304|12.05|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|304||||304|16.49|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|304||||304|10.12|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|304||||304|10.12|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|304||||304|209.76|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|304||||304|10.12|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|Self-pay|Self-pay|304||||304|106.4|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|304||||304|10.12|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|304||||304|10.12|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|304||||304|16.84|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|304||||304|12.05|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|304||||304|12.05|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|304||||304|16.84|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|304||||304|12.05|209.76|10.12
30286256|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FLUOR AB TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|304||||304|24.1|209.76|10.12
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|AARP [1000]|AARP [100000]|310||||310|29.07|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|310||||310|21.02|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|AETNA [1015]|AETNA [101529]|310||||310|28.46|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|310||||310|17.48|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|310||||310|20.81|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|310||||310|20.81|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|BCBS [1155]|BCBS UTHCT [115568]|310||||310|145.7|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|310||||310|31.35|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|310||||310|155|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|310||||310|195.3|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|310||||310|17.48|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|310||||310|20.81|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|CIGNA [1260]|CIGNA GWH [126023]|310||||310|24.07|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|310||||310|213.9|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|310||||310|26.01|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|310||||310|20.81|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|310||||310|28.46|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|310||||310|17.48|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|310||||310|20.81|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|310||||310|28.46|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|310||||310|17.48|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|310||||310|17.48|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|310||||310|213.9|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|310||||310|17.48|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|Self-pay|Self-pay|310||||310|108.5|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|310||||310|17.48|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|310||||310|17.48|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|310||||310|29.07|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|310||||310|20.81|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|310||||310|20.81|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|310||||310|29.07|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|310||||310|20.81|213.9|17.48
30286300|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 15-3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|310||||310|41.62|213.9|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|AARP [1000]|AARP [100000]|326||||326|29.07|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|326||||326|21.02|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|AETNA [1015]|AETNA [101529]|326||||326|28.46|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|326||||326|17.48|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|326||||326|20.81|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|326||||326|20.81|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|BCBS [1155]|BCBS UTHCT [115568]|326||||326|153.22|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|326||||326|31.35|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|326||||326|163|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|326||||326|205.38|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|326||||326|17.48|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|326||||326|20.81|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|CIGNA [1260]|CIGNA GWH [126023]|326||||326|24.07|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|GROUP PENSION ADMIN [1450]|GPA [145000]|326||||326|224.94|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|326||||326|26.01|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|326||||326|20.81|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|326||||326|28.46|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|326||||326|17.48|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|326||||326|20.81|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|326||||326|28.46|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|326||||326|17.48|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|326||||326|17.48|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|PHCS [1780]|PHCS MULTIPLAN [178000]|326||||326|224.94|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|326||||326|17.48|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|Self-pay|Self-pay|326||||326|114.1|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|326||||326|17.48|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|326||||326|17.48|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|326||||326|29.07|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|326||||326|20.81|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|326||||326|20.81|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|326||||326|29.07|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|326||||326|20.81|224.94|17.48
30286301|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 19-9|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|326||||326|41.62|224.94|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|AARP [1000]|AARP [100000]|489||||489|29.07|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|489||||489|21.02|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|AETNA [1015]|AETNA [101529]|489||||489|28.46|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|489||||489|17.48|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|489||||489|20.81|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|489||||489|20.81|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|BCBS [1155]|BCBS UTHCT [115568]|489||||489|229.83|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|489||||489|31.35|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|489||||489|244.5|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|489||||489|308.07|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|489||||489|17.48|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|489||||489|20.81|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|CIGNA [1260]|CIGNA GWH [126023]|489||||489|24.07|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|GROUP PENSION ADMIN [1450]|GPA [145000]|489||||489|337.41|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|489||||489|26.01|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|489||||489|20.81|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|489||||489|28.46|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|489||||489|17.48|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|489||||489|20.81|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|489||||489|28.46|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|489||||489|17.48|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|489||||489|17.48|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|PHCS [1780]|PHCS MULTIPLAN [178000]|489||||489|337.41|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|489||||489|17.48|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|Self-pay|Self-pay|489||||489|171.15|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|489||||489|17.48|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|489||||489|17.48|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|489||||489|29.07|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|489||||489|20.81|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|489||||489|20.81|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|489||||489|29.07|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|489||||489|20.81|337.41|17.48
30286304|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG CA 125|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|489||||489|41.62|337.41|17.48
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|AARP [1000]|AARP [100000]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|AETNA [1015]|AETNA [101529]|360||||360|28.46|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|BCBS [1155]|BCBS UTHCT [115568]|360||||360|169.2|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|360||||360|31.35|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|360||||360|180|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|360||||360|226.8|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|CIGNA [1260]|CIGNA GWH [126023]|360||||360|198|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|GROUP PENSION ADMIN [1450]|GPA [145000]|360||||360|248.4|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|360||||360|26.01|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|360||||360|28.46|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|360||||360|28.46|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|PHCS [1780]|PHCS MULTIPLAN [178000]|360||||360|248.4|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|Self-pay|Self-pay|360||||360|126|248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|360||||360||248.4|26.01
30286305|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HE4 HUMAN EPIDIDY PROTEIN 4|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|360||||360||248.4|26.01
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|AARP [1000]|AARP [100000]|88||||88|7.23|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|88||||88|5.23|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|AETNA [1015]|AETNA [101529]|88||||88|7.08|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|88||||88|4.35|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|88||||88|5.18|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|88||||88|5.18|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|88||||88|41.36|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|88||||88|7.8|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|88||||88|44|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|88||||88|55.44|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|88||||88|4.35|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|88||||88|5.18|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|88||||88|9.52|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|88||||88|60.72|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|88||||88|6.48|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|88||||88|5.18|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|88||||88|7.08|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|88||||88|4.35|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|88||||88|5.18|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|88||||88|7.08|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|88||||88|4.35|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|88||||88|4.35|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|88||||88|60.72|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|88||||88|4.35|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|Self-pay|Self-pay|88||||88|30.8|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|88||||88|4.35|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|88||||88|4.35|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|88||||88|7.23|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|88||||88|5.18|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|88||||88|5.18|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|88||||88|7.23|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|88||||88|5.18|60.72|4.35
30286308|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|88||||88|10.36|60.72|4.35
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|AARP [1000]|AARP [100000]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|AETNA [1015]|AETNA [101529]|31||||31|8.86|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|9.74|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|CIGNA [1260]|CIGNA GWH [126023]|31||||31|7.64|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|8.09|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|8.86|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|8.86|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|Self-pay|Self-pay|31||||31|10.85|21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31||21.39|7.64
30286309|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HETEROPHILE TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31||21.39|7.64
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|AARP [1000]|AARP [100000]|335||||335|29.07|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|335||||335|21.02|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|AETNA [1015]|AETNA [101529]|335||||335|28.46|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|335||||335|17.48|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|335||||335|20.81|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|335||||335|20.81|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|BCBS [1155]|BCBS UTHCT [115568]|335||||335|157.45|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|335||||335|31.35|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|335||||335|167.5|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|335||||335|211.05|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|335||||335|17.48|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|335||||335|20.81|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|CIGNA [1260]|CIGNA GWH [126023]|335||||335|24.07|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|335||||335|231.15|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|335||||335|26.01|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|335||||335|20.81|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|335||||335|28.46|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|335||||335|17.48|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|335||||335|20.81|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|335||||335|28.46|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|335||||335|17.48|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|335||||335|17.48|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|335||||335|231.15|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|335||||335|17.48|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|Self-pay|Self-pay|335||||335|117.25|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|335||||335|17.48|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|335||||335|17.48|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|335||||335|29.07|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|335||||335|20.81|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|335||||335|20.81|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|335||||335|29.07|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|335||||335|20.81|231.15|17.48
30286316|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO TUMOR AG OTHER QN EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|335||||335|41.62|231.15|17.48
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|AARP [1000]|AARP [100000]|1403||||1403|20.95|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1403||||1403|15.14|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|AETNA [1015]|AETNA [101529]|1403||||1403|20.5|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1403||||1403|12.59|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1403||||1403|14.99|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1403||||1403|14.99|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|BCBS [1155]|BCBS UTHCT [115568]|1403||||1403|659.41|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1403||||1403|22.57|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1403||||1403|701.5|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1403||||1403|883.89|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1403||||1403|12.59|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1403||||1403|14.99|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|CIGNA [1260]|CIGNA GWH [126023]|1403||||1403|17.28|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1403||||1403|968.07|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1403||||1403|18.74|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1403||||1403|14.99|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1403||||1403|20.5|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1403||||1403|12.59|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1403||||1403|14.99|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1403||||1403|20.5|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1403||||1403|12.59|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1403||||1403|12.59|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1403||||1403|968.07|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1403||||1403|12.59|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|Self-pay|Self-pay|1403||||1403|491.05|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1403||||1403|12.59|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1403||||1403|12.59|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1403||||1403|20.95|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1403||||1403|14.99|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1403||||1403|14.99|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1403||||1403|20.95|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1403||||1403|14.99|968.07|12.59
30286317|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNO ASSAY INFECT AGENT QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1403||||1403|29.98|968.07|12.59
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|AARP [1000]|AARP [100000]|34||||34|16.75|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34|12.1|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|AETNA [1015]|AETNA [101529]|34||||34|16.39|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34|10.06|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34|11.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34|11.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|BCBS [1155]|BCBS UTHCT [115568]|34||||34|15.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|18.04|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|21.42|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34|10.06|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34|11.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|CIGNA [1260]|CIGNA GWH [126023]|34||||34|13.88|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34||||34|14.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34|11.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|16.39|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34|10.06|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34|11.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|16.39|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34|10.06|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34||||34|10.06|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34|10.06|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|Self-pay|Self-pay|34||||34|11.9|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34||||34|10.06|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34|10.06|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34|16.75|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34||||34|11.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34||||34|11.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34|16.75|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34|11.98|23.96|10.06
30286331|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNODIFFUSION GEL QUAL EA AG/ANTBDY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34|23.96|23.96|10.06
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|AARP [1000]|AARP [100000]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|AETNA [1015]|AETNA [101529]|189||||189|33.34|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|36.71|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|28.32|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|30.46|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|33.34|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|33.34|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|Self-pay|Self-pay|189||||189|66.15|130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189||130.41|28.32
30286332|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNE COMPLEX ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189||130.41|28.32
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AARP [1000]|AARP [100000]|363||||363|31.21|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|363||||363|22.56|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AETNA [1015]|AETNA [101529]|363||||363|30.55|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|363||||363|18.77|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|363||||363|22.34|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|363||||363|22.34|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS [1155]|BCBS UTHCT [115568]|363||||363|170.61|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|363||||363|33.66|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|363||||363|181.5|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|363||||363|228.69|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|363||||363|18.77|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|363||||363|22.34|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|CIGNA [1260]|CIGNA GWH [126023]|363||||363|39.17|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|363||||363|250.47|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|363||||363|27.93|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|363||||363|22.34|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|363||||363|30.55|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|363||||363|18.77|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|363||||363|22.34|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|363||||363|30.55|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|363||||363|18.77|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|363||||363|18.77|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|363||||363|250.47|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|363||||363|18.77|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|Self-pay|Self-pay|363||||363|127.05|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|363||||363|18.77|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|363||||363|18.77|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|363||||363|31.21|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|363||||363|22.34|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|363||||363|22.34|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|363||||363|31.21|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|363||||363|22.34|250.47|18.77
30286334|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFIX ELECTROPHOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|363||||363|44.68|250.47|18.77
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AARP [1000]|AARP [100000]|414||||414|41|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|414||||414|29.64|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AETNA [1015]|AETNA [101529]|414||||414|40.15|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|414||||414|24.65|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|414||||414|29.35|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|414||||414|29.35|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS [1155]|BCBS UTHCT [115568]|414||||414|194.58|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|414||||414|44.2|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|414||||414|207|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|414||||414|260.82|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|414||||414|24.65|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|414||||414|29.35|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|CIGNA [1260]|CIGNA GWH [126023]|414||||414|47.1|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|414||||414|285.66|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|414||||414|36.69|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|414||||414|29.35|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|414||||414|40.15|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|414||||414|24.65|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|414||||414|29.35|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|414||||414|40.15|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|414||||414|24.65|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|414||||414|24.65|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|414||||414|285.66|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|414||||414|24.65|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|Self-pay|Self-pay|414||||414|144.9|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|414||||414|24.65|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|414||||414|24.65|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|414||||414|41|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|414||||414|29.35|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|414||||414|29.35|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|414||||414|41|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|414||||414|29.35|285.66|24.65
30286335|EAP|0302 - LABORATORY-IMMUNOLOGY|HC IMMUNOFX ELECTROPHR FLD W/CON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|414||||414|58.7|285.66|24.65
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|AARP [1000]|AARP [100000]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|AETNA [1015]|AETNA [101529]|120||||120|21.34|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|BCBS [1155]|BCBS UTHCT [115568]|120||||120|56.4|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|120||||120|23.47|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|120||||120|60|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|120||||120|75.6|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|CIGNA [1260]|CIGNA GWH [126023]|120||||120|18.13|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|GROUP PENSION ADMIN [1450]|GPA [145000]|120||||120|82.8|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|120||||120|19.49|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|120||||120|21.34|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|120||||120|21.34|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|PHCS [1780]|PHCS MULTIPLAN [178000]|120||||120|82.8|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|Self-pay|Self-pay|120||||120|42|82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|120||||120||82.8|18.13
30286336|EAP|0302 - LABORATORY-IMMUNOLOGY|HC INHIBIN A|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|120||||120||82.8|18.13
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|AARP [1000]|AARP [100000]|163||||163|29.92|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163||||163|21.62|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|AETNA [1015]|AETNA [101529]|163||||163|29.28|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163||||163|17.98|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163||||163|21.41|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163||||163|21.41|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|BCBS [1155]|BCBS UTHCT [115568]|163||||163|76.61|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163||||163|32.24|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163||||163|81.5|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163||||163|102.69|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163||||163|17.98|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163||||163|21.41|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|CIGNA [1260]|CIGNA GWH [126023]|163||||163|24.92|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163||||163|112.47|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|163||||163|26.76|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163||||163|21.41|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163||||163|29.28|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163||||163|17.98|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163||||163|21.41|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163||||163|29.28|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163||||163|17.98|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|163||||163|17.98|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163||||163|112.47|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163||||163|17.98|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|Self-pay|Self-pay|163||||163|57.05|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|163||||163|17.98|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163||||163|17.98|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163||||163|29.92|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|163||||163|21.41|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|163||||163|21.41|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163||||163|29.92|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163||||163|21.41|112.47|17.98
30286337|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INSULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163||||163|42.82|112.47|17.98
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AARP [1000]|AARP [100000]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AETNA [1015]|AETNA [101529]|187||||187|20.64|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS [1155]|BCBS UTHCT [115568]|187||||187|87.89|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|187||||187|22.7|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|187||||187|93.5|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|187||||187|117.81|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|CIGNA [1260]|CIGNA GWH [126023]|187||||187|17.57|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|187||||187|129.03|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|187||||187|18.85|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|187||||187|20.64|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|187||||187|20.64|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|187||||187|129.03|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|Self-pay|Self-pay|187||||187|65.45|129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|187||||187||129.03|17.57
30286340|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INTRINSIC FACTOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|187||||187||129.03|17.57
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AARP [1000]|AARP [100000]|531||||531|27.65|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|531||||531|23.81|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AETNA [1015]|AETNA [101529]|531||||531|32.23|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|531||||531|19.8|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|531||||531|23.57|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|531||||531|23.57|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BCBS UTHCT [115568]|531||||531|249.57|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|531||||531|29.8|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|531||||531|265.5|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|531||||531|334.53|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|531||||531|19.8|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|531||||531|23.57|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|CIGNA [1260]|CIGNA GWH [126023]|531||||531|22.94|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|531||||531|366.39|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|531||||531|29.46|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|531||||531|23.57|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|531||||531|32.23|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|531||||531|19.8|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|531||||531|23.57|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|531||||531|32.23|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|531||||531|19.8|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|531||||531|19.8|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|531||||531|366.39|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|531||||531|19.8|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|Self-pay|Self-pay|531||||531|185.85|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|531||||531|19.8|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|531||||531|19.8|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|531||||531|27.65|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|531||||531|23.57|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|531||||531|23.57|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|531||||531|27.65|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|531||||531|23.57|366.39|19.8
30286341|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ISLET CELL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|531||||531|47.14|366.39|19.8
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|AARP [1000]|AARP [100000]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|AETNA [1015]|AETNA [101529]|720||||720|185.86|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|BCBS [1155]|BCBS UTHCT [115568]|720||||720|338.4|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|720||||720|204.63|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|720||||720|360|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|720||||720|453.6|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|CIGNA [1260]|CIGNA GWH [126023]|720||||720|396|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|720||||720|496.8|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|720||||720|169.83|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|720||||720|185.86|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|720||||720|185.86|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|720||||720|496.8|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|Self-pay|Self-pay|720||||720|252|496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|720||||720||496.8|169.83
30286352|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CELL FUNCT ASSAY/STIM BIOMARK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|720||||720||496.8|169.83
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|AARP [1000]|AARP [100000]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|AETNA [1015]|AETNA [101529]|267||||267|67.08|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|BCBS [1155]|BCBS UTHCT [115568]|267||||267|125.49|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|267||||267|73.85|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|267||||267|133.5|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|267||||267|168.21|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|CIGNA [1260]|CIGNA GWH [126023]|267||||267|56.94|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|267||||267|184.23|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|267||||267|61.29|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|267||||267|67.08|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|267||||267|67.08|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|267||||267|184.23|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|Self-pay|Self-pay|267||||267|93.45|184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|267||||267||184.23|56.94
30286353|EAP|0302 - LABORATORY-IMMUNOLOGY|HC LYMPHOCYTE TRANSFORMATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|267||||267||184.23|56.94
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|AARP [1000]|AARP [100000]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|AETNA [1015]|AETNA [101529]|154||||154|51.62|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|BCBS [1155]|BCBS UTHCT [115568]|154||||154|72.38|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|154||||154|56.83|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|154||||154|77|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|154||||154|97.02|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|CIGNA [1260]|CIGNA GWH [126023]|154||||154|43.91|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|154||||154|106.26|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|154||||154|47.16|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|154||||154|51.62|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|154||||154|51.62|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|154||||154|106.26|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|Self-pay|Self-pay|154||||154|53.9|106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|154||||154||106.26|43.91
30286355|EAP|0302 - LABORATORY-IMMUNOLOGY|HC B CELLS TOTAL COUNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|154||||154||106.26|43.91
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|AARP [1000]|AARP [100000]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|AETNA [1015]|AETNA [101529]|264||||264|36.62|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|BCBS [1155]|BCBS UTHCT [115568]|264||||264|124.08|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264||||264|40.33|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264||||264|132|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264||||264|166.32|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|CIGNA [1260]|CIGNA GWH [126023]|264||||264|31.16|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264||||264|182.16|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|264||||264|33.48|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264||||264|36.62|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264||||264|36.62|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264||||264|182.16|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|Self-pay|Self-pay|264||||264|92.4|182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264||||264||182.16|31.16
30286356|EAP|0302 - LABORATORY-IMMUNOLOGY|HC MONONUCLEAR CELL ANTIGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264||||264||182.16|31.16
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|AARP [1000]|AARP [100000]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|AETNA [1015]|AETNA [101529]|133||||133|51.62|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|BCBS [1155]|BCBS UTHCT [115568]|133||||133|62.51|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|133||||133|56.83|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|133||||133|66.5|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|133||||133|83.79|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|CIGNA [1260]|CIGNA GWH [126023]|133||||133|43.91|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|133||||133|91.77|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|133||||133|47.16|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|133||||133|51.62|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|133||||133|51.62|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|133||||133|91.77|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|Self-pay|Self-pay|133||||133|46.55|91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|133||||133||91.77|43.91
30286357|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NK CELLS TOTAL COUNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|133||||133||91.77|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|AARP [1000]|AARP [100000]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|AETNA [1015]|AETNA [101529]|141||||141|51.62|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|141||||141|66.27|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|141||||141|56.83|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|141||||141|70.5|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|141||||141|88.83|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|141||||141|43.91|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|141||||141|97.29|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|141||||141|47.16|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|141||||141|51.62|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|141||||141|51.62|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|141||||141|97.29|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|Self-pay|Self-pay|141||||141|49.35|97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|141||||141||97.29|43.91
30286359|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|141||||141||97.29|43.91
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|AARP [1000]|AARP [100000]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|AETNA [1015]|AETNA [101529]|175||||175|64.27|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|BCBS [1155]|BCBS UTHCT [115568]|175||||175|82.25|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|175||||175|70.77|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|175||||175|87.5|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|175||||175|110.25|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|CIGNA [1260]|CIGNA GWH [126023]|175||||175|54.67|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|175||||175|120.75|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|175||||175|58.73|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|175||||175|64.27|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|175||||175|64.27|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|175||||175|120.75|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|Self-pay|Self-pay|175||||175|61.25|120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|175||||175||120.75|54.67
30286360|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 & CD8 W/RATIO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|175||||175||120.75|54.67
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|AARP [1000]|AARP [100000]|344||||344|37.41|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|344||||344|27.05|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|AETNA [1015]|AETNA [101529]|344||||344|36.62|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|344||||344|22.5|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|344||||344|26.78|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|344||||344|26.78|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|BCBS [1155]|BCBS UTHCT [115568]|344||||344|161.68|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|344||||344|40.33|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|344||||344|172|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|344||||344|216.72|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|344||||344|22.5|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|344||||344|26.78|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|CIGNA [1260]|CIGNA GWH [126023]|344||||344|31.16|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|344||||344|237.36|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|344||||344|33.48|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|344||||344|26.78|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|344||||344|36.62|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|344||||344|22.5|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|344||||344|26.78|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|344||||344|36.62|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|344||||344|22.5|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|344||||344|22.5|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|344||||344|237.36|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|344||||344|22.5|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|Self-pay|Self-pay|344||||344|120.4|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|344||||344|22.5|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|344||||344|22.5|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|344||||344|37.41|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|344||||344|26.78|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|344||||344|26.78|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|344||||344|37.41|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|344||||344|26.78|237.36|22.5
30286361|EAP|0302 - LABORATORY-IMMUNOLOGY|HC T CELLS CD4 CNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|344||||344|53.56|237.36|22.5
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AARP [1000]|AARP [100000]|93||||93|20.33|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93|14.7|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AETNA [1015]|AETNA [101529]|93||||93|19.9|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|12.22|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93|14.55|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93|14.55|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS [1155]|BCBS UTHCT [115568]|93||||93|43.71|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|21.91|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|46.5|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|58.59|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|12.22|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93|14.55|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|CIGNA [1260]|CIGNA GWH [126023]|93||||93|16.99|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|93||||93|18.19|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93|14.55|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|19.9|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|12.22|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93|14.55|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|19.9|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|12.22|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|93||||93|12.22|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|12.22|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|Self-pay|Self-pay|93||||93|32.55|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|93||||93|12.22|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93|12.22|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93|20.33|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|93||||93|14.55|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|93||||93|14.55|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93|20.33|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93|14.55|64.17|12.22
30286376|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MICROSOMAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93|29.1|64.17|12.22
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|AARP [1000]|AARP [100000]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|AETNA [1015]|AETNA [101529]|393||||393|23.14|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|BCBS [1155]|BCBS UTHCT [115568]|393||||393|184.71|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|393||||393|25.47|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|393||||393|196.5|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|393||||393|247.59|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|CIGNA [1260]|CIGNA GWH [126023]|393||||393|19.54|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|393||||393|271.17|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|393||||393|21.14|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|393||||393|23.14|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|393||||393|23.14|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|393||||393|271.17|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|Self-pay|Self-pay|393||||393|137.55|271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|393||||393||271.17|19.54
30286382|EAP|0302 - LABORATORY-IMMUNOLOGY|HC NEUTRALIZATION VIRAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|393||||393||271.17|19.54
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AARP [1000]|AARP [100000]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AETNA [1015]|AETNA [101529]|191||||191|15.79|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|191||||191|89.77|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|191||||191|15.35|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|191||||191|95.5|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|191||||191|120.33|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|191||||191|19.03|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|191||||191|131.79|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|191||||191|14.43|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|191||||191|15.79|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|191||||191|15.79|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|191||||191|131.79|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|Self-pay|Self-pay|191||||191|66.85|131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|191||||191||131.79|14.43
30286403|EAP|0302 - LABORATORY-IMMUNOLOGY|HC PARTICLE AGGLUT SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|191||||191||131.79|14.43
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|AARP [1000]|AARP [100000]|120||||120|7.93|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|120||||120|5.73|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|AETNA [1015]|AETNA [101529]|120||||120|7.75|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|120||||120|4.76|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|120||||120|5.67|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|120||||120|5.67|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|BCBS [1155]|BCBS UTHCT [115568]|120||||120|56.4|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|120||||120|8.54|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|120||||120|60|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|120||||120|75.6|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|120||||120|4.76|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|120||||120|5.67|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|CIGNA [1260]|CIGNA GWH [126023]|120||||120|6.5|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|120||||120|82.8|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|120||||120|7.09|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|120||||120|5.67|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|120||||120|7.75|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|120||||120|4.76|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|120||||120|5.67|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|120||||120|7.75|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|120||||120|4.76|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|120||||120|4.76|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|120||||120|82.8|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|120||||120|4.76|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|Self-pay|Self-pay|120||||120|42|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|120||||120|4.76|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|120||||120|4.76|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|120||||120|7.93|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|120||||120|5.67|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|120||||120|5.67|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|120||||120|7.93|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|120||||120|5.67|82.8|4.76
30286431|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RHEUMATOID FACTOR QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|120||||120|11.34|82.8|4.76
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AARP [1000]|AARP [100000]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AETNA [1015]|AETNA [101529]|231||||231|84.79|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS [1155]|BCBS UTHCT [115568]|231||||231|108.57|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|231||||231|93.35|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|231||||231|115.5|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|231||||231|145.53|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|CIGNA [1260]|CIGNA GWH [126023]|231||||231|71.95|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|231||||231|159.39|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|231||||231|77.48|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|231||||231|84.79|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|231||||231|84.79|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|231||||231|159.39|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|Self-pay|Self-pay|231||||231|80.85|159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|231||||231||159.39|71.95
30286480|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB TEST CELL IMMUNITY MEASURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|231||||231||159.39|71.95
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AARP [1000]|AARP [100000]|231||||231|87.22|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|231||||231|101|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AETNA [1015]|AETNA [101529]|231||||231|136.8|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|231||||231|84|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|231||||231|100|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|231||||231|100|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS [1155]|BCBS UTHCT [115568]|231||||231|108.57|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|231||||231|122|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|231||||231|115.5|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|231||||231|145.53|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|231||||231|84|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|231||||231|100|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|CIGNA [1260]|CIGNA GWH [126023]|231||||231|127.05|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|231||||231|159.39|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|231||||231|125|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|231||||231|100|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|231||||231|136.8|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|231||||231|84|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|231||||231|100|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|231||||231|136.8|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|231||||231|84|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|231||||231|84|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|231||||231|159.39|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|231||||231|84|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|Self-pay|Self-pay|231||||231|80.85|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|231||||231|84|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|231||||231|84|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|231||||231|87.22|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|231||||231|100|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|231||||231|100|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|231||||231|87.22|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|231||||231|100|200|80.85
30286481|EAP|0302 - LABORATORY-IMMUNOLOGY|HC TB AG RESPONSE GAMMA INTERFERON T-CELL SUSP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|231||||231|200|200|80.85
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AARP [1000]|AARP [100000]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AETNA [1015]|AETNA [101529]|90||||90|12.91|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|90||||90|26.69|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BCBS UTHCT [115568]|90||||90|42.3|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|90||||90|21.31|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|90||||90|45|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|90||||90|56.7|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|90||||90|26.69|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|CIGNA [1260]|CIGNA GWH [126023]|90||||90|10.01|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|90||||90|62.1|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|90||||90|30.84|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|90||||90|12.91|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|90||||90|26.69|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|90||||90|12.91|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|90||||90|26.69|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|90||||90|26.69|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|90||||90|62.1|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|90||||90|26.69|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|Self-pay|Self-pay|90||||90|31.5|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|90||||90|26.69|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|90||||90|26.69|62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|90||||90||62.1|10.01
30286580|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SKIN TEST TB INTRADERMAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|90||||90||62.1|10.01
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AARP [1000]|AARP [100000]|86||||86|5.96|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|86||||86|4.31|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AETNA [1015]|AETNA [101529]|86||||86|5.83|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|86||||86|3.59|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|86||||86|4.27|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|86||||86|4.27|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BCBS UTHCT [115568]|86||||86|40.42|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|86||||86|6.43|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|86||||86|43|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|86||||86|54.18|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|86||||86|3.59|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|86||||86|4.27|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|CIGNA [1260]|CIGNA GWH [126023]|86||||86|4.81|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|86||||86|59.34|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|86||||86|5.34|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|86||||86|4.27|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86||||86|5.83|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|86||||86|3.59|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|86||||86|4.27|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|86||||86|5.83|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|86||||86|3.59|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|86||||86|3.59|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|86||||86|59.34|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|86||||86|3.59|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|Self-pay|Self-pay|86||||86|30.1|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|86||||86|3.59|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|86||||86|3.59|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|86||||86|5.96|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|86||||86|4.27|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|86||||86|4.27|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|86||||86|5.96|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|86||||86|4.27|59.34|3.59
30286592|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS VDRL/RPR QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|86||||86|8.54|59.34|3.59
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|AARP [1000]|AARP [100000]|55||||55|6.16|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|55||||55|4.44|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|AETNA [1015]|AETNA [101529]|55||||55|6.02|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55||||55|3.7|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55||||55|4.4|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|55||||55|4.4|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|BCBS [1155]|BCBS UTHCT [115568]|55||||55|25.85|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|55||||55|6.64|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|55||||55|27.5|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|55||||55|34.65|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|55||||55|3.7|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|55||||55|4.4|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|CIGNA [1260]|CIGNA GWH [126023]|55||||55|5.1|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|55||||55|37.95|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|55||||55|5.5|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|55||||55|4.4|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55||||55|6.02|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|55||||55|3.7|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|55||||55|4.4|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55||||55|6.02|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|55||||55|3.7|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|55||||55|3.7|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|55||||55|37.95|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|55||||55|3.7|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|Self-pay|Self-pay|55||||55|19.25|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|55||||55|3.7|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|55||||55|3.7|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55||||55|6.16|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|55||||55|4.4|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|55||||55|4.4|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|55||||55|6.16|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|55||||55|4.4|37.95|3.7
30286593|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SYPHILIS NON-TREP AB QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|55||||55|8.8|37.95|3.7
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|AARP [1000]|AARP [100000]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|AETNA [1015]|AETNA [101529]|105||||105|17.62|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|BCBS [1155]|BCBS UTHCT [115568]|105||||105|49.35|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105||||105|19.39|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105||||105|52.5|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105||||105|66.15|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|CIGNA [1260]|CIGNA GWH [126023]|105||||105|15.02|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|105||||105|72.45|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105||||105|16.09|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105||||105|17.62|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105||||105|17.62|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|105||||105|72.45|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|Self-pay|Self-pay|105||||105|36.75|72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105||||105||72.45|15.02
30286603|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ADENOVIRUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105||||105||72.45|15.02
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|AARP [1000]|AARP [100000]|116||||116|21.03|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116|15.2|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|AETNA [1015]|AETNA [101529]|116||||116|20.59|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116|12.64|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116|15.05|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116|15.05|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|22.68|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116|12.64|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116|15.05|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|17.57|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|18.81|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116|15.05|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|20.59|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116|12.64|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116|15.05|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|20.59|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116|12.64|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116|12.64|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116|12.64|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|Self-pay|Self-pay|116||||116|40.6|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116|12.64|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116|12.64|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116|21.03|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116|15.05|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116|15.05|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116|21.03|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116|15.05|80.04|12.64
30286606|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ASPERGILLUS AB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116|30.1|80.04|12.64
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|AARP [1000]|AARP [100000]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|AETNA [1015]|AETNA [101529]|226||||226|17.62|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|BCBS [1155]|BCBS UTHCT [115568]|226||||226|106.22|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|226||||226|19.4|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|226||||226|113|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|226||||226|142.38|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|CIGNA [1260]|CIGNA GWH [126023]|226||||226|15.02|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|226||||226|155.94|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|226||||226|16.1|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|226||||226|17.62|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|226||||226|17.62|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|226||||226|155.94|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|Self-pay|Self-pay|226||||226|79.1|155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|226||||226||155.94|15.02
30286609|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BACTERIUM NOT SPECIFIED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|226||||226||155.94|15.02
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AARP [1000]|AARP [100000]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AETNA [1015]|AETNA [101529]|146||||146|13.92|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BCBS UTHCT [115568]|146||||146|68.62|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|15.32|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|91.98|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|CIGNA [1260]|CIGNA GWH [126023]|146||||146|11.89|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|146||||146|12.73|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|13.92|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|13.92|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|Self-pay|Self-pay|146||||146|51.1|100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146||100.74|11.89
30286611|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BARTONELLA AB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146||||146||100.74|11.89
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|AARP [1000]|AARP [100000]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|AETNA [1015]|AETNA [101529]|50||||50|17.64|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|BCBS [1155]|BCBS UTHCT [115568]|50||||50|23.5|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50||||50|19.43|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50||||50|25|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50||||50|31.5|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|CIGNA [1260]|CIGNA GWH [126023]|50||||50|15.02|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|50||||50|34.5|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50||||50|16.13|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50||||50|17.64|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50||||50|17.64|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|50||||50|34.5|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|Self-pay|Self-pay|50||||50|17.5|34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50||||50||34.5|15.02
30286612|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BLASTOMYCES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50||||50||34.5|15.02
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|AARP [1000]|AARP [100000]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|AETNA [1015]|AETNA [101529]|259||||259|18.05|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|BCBS [1155]|BCBS UTHCT [115568]|259||||259|121.73|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|259||||259|19.86|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|259||||259|129.5|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|259||||259|163.17|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|CIGNA [1260]|CIGNA GWH [126023]|259||||259|15.29|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|259||||259|178.71|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|259||||259|16.49|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|259||||259|18.05|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|259||||259|18.05|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|259||||259|178.71|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|Self-pay|Self-pay|259||||259|90.65|178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|259||||259||178.71|15.29
30286615|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BORDETELLA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|259||||259||178.71|15.29
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|AARP [1000]|AARP [100000]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|AETNA [1015]|AETNA [101529]|34||||34|21.19|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|BCBS [1155]|BCBS UTHCT [115568]|34||||34|15.98|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|23.34|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|21.42|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|CIGNA [1260]|CIGNA GWH [126023]|34||||34|18.13|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34||||34|19.36|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|21.19|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|21.19|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|Self-pay|Self-pay|34||||34|11.9|23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34||23.46|11.9
30286617|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE W/BLOT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34||23.46|11.9
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AARP [1000]|AARP [100000]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AETNA [1015]|AETNA [101529]|261||||261|23.3|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BCBS UTHCT [115568]|261||||261|122.67|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|261||||261|25.64|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|261||||261|130.5|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|261||||261|164.43|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|CIGNA [1260]|CIGNA GWH [126023]|261||||261|19.82|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|261||||261|180.09|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|261||||261|21.29|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|261||||261|23.3|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|261||||261|23.3|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|261||||261|180.09|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|Self-pay|Self-pay|261||||261|91.35|180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|261||||261||180.09|19.82
30286618|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYME DISEASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|261||||261||180.09|19.82
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|AARP [1000]|AARP [100000]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|AETNA [1015]|AETNA [101529]|65||||65|12.22|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|BCBS [1155]|BCBS UTHCT [115568]|65||||65|30.55|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65||||65|13.46|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65||||65|32.5|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65||||65|40.95|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|CIGNA [1260]|CIGNA GWH [126023]|65||||65|10.49|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|65||||65|44.85|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65||||65|11.16|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65||||65|12.22|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65||||65|12.22|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|65||||65|44.85|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|Self-pay|Self-pay|65||||65|22.75|44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65||||65||44.85|10.49
30286622|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB BRUCELLA IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65||||65||44.85|10.49
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|AARP [1000]|AARP [100000]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|AETNA [1015]|AETNA [101529]|58||||58|16.44|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|BCBS [1155]|BCBS UTHCT [115568]|58||||58|27.26|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58||||58|18.08|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58||||58|29|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58||||58|36.54|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|CIGNA [1260]|CIGNA GWH [126023]|58||||58|13.88|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|58||||58|40.02|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58||||58|15.01|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58||||58|16.44|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58||||58|16.44|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|58||||58|40.02|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|Self-pay|Self-pay|58||||58|20.3|40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58||||58||40.02|13.88
30286628|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CANDIDA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58||||58||40.02|13.88
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AARP [1000]|AARP [100000]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AETNA [1015]|AETNA [101529]|301||||301|16.18|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS [1155]|BCBS UTHCT [115568]|301||||301|141.47|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|301||||301|17.81|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|301||||301|150.5|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|301||||301|189.63|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|CIGNA [1260]|CIGNA GWH [126023]|301||||301|13.6|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|301||||301|207.69|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|301||||301|14.78|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|301||||301|16.18|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|301||||301|16.18|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|301||||301|207.69|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|Self-pay|Self-pay|301||||301|105.35|207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|301||||301||207.69|13.6
30286631|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CHLAMYDIA AB QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|301||||301||207.69|13.6
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AARP [1000]|AARP [100000]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AETNA [1015]|AETNA [101529]|103||||103|17.35|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS [1155]|BCBS UTHCT [115568]|103||||103|48.41|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|103||||103|19.11|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|103||||103|51.5|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|103||||103|64.89|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|CIGNA [1260]|CIGNA GWH [126023]|103||||103|14.74|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|103||||103|71.07|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|103||||103|15.85|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|103||||103|17.35|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|103||||103|17.35|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|103||||103|71.07|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|Self-pay|Self-pay|103||||103|36.05|71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|103||||103||71.07|14.74
30286632|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CHLAMYDIA IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|103||||103||71.07|14.74
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AARP [1000]|AARP [100000]|70||||70|16.03|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70||||70|11.58|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AETNA [1015]|AETNA [101529]|70||||70|15.7|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70||||70|9.63|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70||||70|11.47|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70||||70|11.47|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BCBS UTHCT [115568]|70||||70|32.9|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70||||70|17.29|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70||||70|35|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70||||70|44.1|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70||||70|9.63|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70||||70|11.47|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|CIGNA [1260]|CIGNA GWH [126023]|70||||70|13.32|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70||||70|48.3|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70||||70|14.34|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70||||70|11.47|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70||||70|15.7|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70||||70|9.63|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70||||70|11.47|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70||||70|15.7|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70||||70|9.63|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70||||70|9.63|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70||||70|48.3|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70||||70|9.63|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|Self-pay|Self-pay|70||||70|24.5|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70||||70|9.63|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70||||70|9.63|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70||||70|16.03|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70||||70|11.47|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70||||70|11.47|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70||||70|16.03|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70||||70|11.47|48.3|9.63
30286635|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COCCIDIOIDES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70||||70|22.94|48.3|9.63
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AARP [1000]|AARP [100000]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AETNA [1015]|AETNA [101529]|23||||23|16.58|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BCBS UTHCT [115568]|23||||23|10.81|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23||||23|18.26|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23||||23|11.5|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23||||23|14.49|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|CIGNA [1260]|CIGNA GWH [126023]|23||||23|14.17|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|23||||23|15.87|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23||||23|15.15|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23||||23|16.58|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23||||23|16.58|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|23||||23|15.87|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|Self-pay|Self-pay|23||||23|8.05|18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23||||23||18.26|8.05
30286638|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB COXIELLA BRUNETII(Q FEVER)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23||||23||18.26|8.05
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AARP [1000]|AARP [100000]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AETNA [1015]|AETNA [101529]|266||||266|19.68|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS [1155]|BCBS UTHCT [115568]|266||||266|125.02|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|266||||266|21.68|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|266||||266|133|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|266||||266|167.58|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|CIGNA [1260]|CIGNA GWH [126023]|266||||266|16.72|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|266||||266|183.54|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|266||||266|17.99|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|266||||266|19.68|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|266||||266|19.68|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|266||||266|183.54|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|Self-pay|Self-pay|266||||266|93.1|183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|266||||266||183.54|16.72
30286644|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|266||||266||183.54|16.72
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AARP [1000]|AARP [100000]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AETNA [1015]|AETNA [101529]|216||||216|23.04|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|25.38|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|19.54|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|21.06|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|23.04|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|23.04|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|Self-pay|Self-pay|216||||216|75.6|149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216||149.04|19.54
30286645|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB CYTOMEGALOVIRUS (CMV) IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216||149.04|19.54
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AARP [1000]|AARP [100000]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AETNA [1015]|AETNA [101529]|69.3||||69.3|17.83|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS [1155]|BCBS UTHCT [115568]|69.3||||69.3|32.57|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69.3||||69.3|19.62|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69.3||||69.3|34.65|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69.3||||69.3|43.66|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|CIGNA [1260]|CIGNA GWH [126023]|69.3||||69.3|15.02|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69.3||||69.3|47.82|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|69.3||||69.3|16.29|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.3||||69.3|17.83|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69.3||||69.3|17.83|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69.3||||69.3|47.82|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|Self-pay|Self-pay|69.3||||69.3|24.25|47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69.3||||69.3||47.82|15.02
30286658|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB ENTEROVIRUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69.3||||69.3||47.82|15.02
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|AARP [1000]|AARP [100000]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|AETNA [1015]|AETNA [101529]|29||||29|17.95|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|BCBS [1155]|BCBS UTHCT [115568]|29||||29|13.63|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29||||29|19.76|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29||||29|14.5|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29||||29|18.27|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|CIGNA [1260]|CIGNA GWH [126023]|29||||29|15.29|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|29||||29|20.01|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29||||29|16.4|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29||||29|17.95|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29||||29|17.95|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|29||||29|20.01|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|Self-pay|Self-pay|29||||29|10.15|20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29||||29||20.01|10.15
30286663|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBEA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29||||29||20.01|10.15
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AARP [1000]|AARP [100000]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AETNA [1015]|AETNA [101529]|159||||159|20.93|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS [1155]|BCBS UTHCT [115568]|159||||159|74.73|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|159||||159|23.03|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|159||||159|79.5|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|159||||159|100.17|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|CIGNA [1260]|CIGNA GWH [126023]|159||||159|17.84|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|159||||159|109.71|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|159||||159|19.11|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|159||||159|20.93|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|159||||159|20.93|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|159||||159|109.71|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|Self-pay|Self-pay|159||||159|55.65|109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|159||||159||109.71|17.84
30286664|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR (EBNA)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|159||||159||109.71|17.84
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AARP [1000]|AARP [100000]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AETNA [1015]|AETNA [101529]|167||||167|24.82|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS [1155]|BCBS UTHCT [115568]|167||||167|78.49|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|167||||167|27.33|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|167||||167|83.5|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|167||||167|105.21|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|CIGNA [1260]|CIGNA GWH [126023]|167||||167|20.96|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|167||||167|115.23|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|167||||167|22.68|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|167||||167|24.82|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|167||||167|24.82|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|167||||167|115.23|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|Self-pay|Self-pay|167||||167|58.45|115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|167||||167||115.23|20.96
30286665|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EPSTEIN-BARR VCA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|167||||167||115.23|20.96
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|AARP [1000]|AARP [100000]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|AETNA [1015]|AETNA [101529]|18||||18|13.92|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|BCBS [1155]|BCBS UTHCT [115568]|18||||18|8.46|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18||||18|15.32|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18||||18|9|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18||||18|11.34|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|CIGNA [1260]|CIGNA GWH [126023]|18||||18|11.89|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|18||||18|12.42|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18||||18|12.73|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18||||18|13.92|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18||||18|13.92|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|18||||18|12.42|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|Self-pay|Self-pay|18||||18|6.3|15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18||||18||15.32|6.3
30286666|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB EHRLICHIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18||||18||15.32|6.3
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|AARP [1000]|AARP [100000]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|AETNA [1015]|AETNA [101529]|79||||79|19.37|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|BCBS [1155]|BCBS UTHCT [115568]|79||||79|37.13|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79||||79|17.28|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79||||79|39.5|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79||||79|49.77|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|CIGNA [1260]|CIGNA GWH [126023]|79||||79|12.18|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|79||||79|54.51|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|79||||79|17.7|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79||||79|19.37|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79||||79|19.37|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|79||||79|54.51|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|Self-pay|Self-pay|79||||79|27.65|54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79||||79||54.51|12.18
30286668|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FRANCISELLA TULARENSIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79||||79||54.51|12.18
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AARP [1000]|AARP [100000]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AETNA [1015]|AETNA [101529]|150||||150|16.75|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BCBS UTHCT [115568]|150||||150|70.5|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|150||||150|18.46|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|150||||150|75|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|150||||150|94.5|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|CIGNA [1260]|CIGNA GWH [126023]|150||||150|14.17|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|150||||150|103.5|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|150||||150|15.31|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|150||||150|16.75|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|150||||150|16.75|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|150||||150|103.5|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|Self-pay|Self-pay|150||||150|52.5|103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|150||||150||103.5|14.17
30286671|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB FUNGUS NOT ELSEWHERE SPECIFIED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|150||||150||103.5|14.17
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|AARP [1000]|AARP [100000]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|AETNA [1015]|AETNA [101529]|140||||140|20.14|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|BCBS [1155]|BCBS UTHCT [115568]|140||||140|65.8|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|140||||140|22.17|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|140||||140|70|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|140||||140|88.2|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|CIGNA [1260]|CIGNA GWH [126023]|140||||140|16.99|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|140||||140|96.6|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|140||||140|18.4|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|140||||140|20.14|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|140||||140|20.14|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|140||||140|96.6|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|Self-pay|Self-pay|140||||140|49|96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|140||||140||96.6|16.99
30286674|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB GIARDIA LAMBLIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|140||||140||96.6|16.99
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AARP [1000]|AARP [100000]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AETNA [1015]|AETNA [101529]|222||||222|17.81|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BCBS UTHCT [115568]|222||||222|104.34|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|222||||222|19.59|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|222||||222|111|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|222||||222|139.86|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|CIGNA [1260]|CIGNA GWH [126023]|222||||222|15.02|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|222||||222|153.18|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|222||||222|16.26|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|222||||222|17.81|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|222||||222|17.81|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|222||||222|153.18|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|Self-pay|Self-pay|222||||222|77.7|153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|222||||222||153.18|15.02
30286682|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HELMINTH NOT ELSEWHERE SPECIFIED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|222||||222||153.18|15.02
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|AARP [1000]|AARP [100000]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|AETNA [1015]|AETNA [101529]|66||||66|26.47|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|BCBS [1155]|BCBS UTHCT [115568]|66||||66|31.02|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|29.16|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|41.58|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|CIGNA [1260]|CIGNA GWH [126023]|66||||66|22.38|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66||||66|24.19|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|26.47|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|26.47|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|Self-pay|Self-pay|66||||66|23.1|45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|22.38
30286689|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HTLV/HIV CONFIRM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|22.38
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|AARP [1000]|AARP [100000]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|AETNA [1015]|AETNA [101529]|97||||97|23.47|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|BCBS [1155]|BCBS UTHCT [115568]|97||||97|45.59|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|97||||97|25.85|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|97||||97|48.5|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|97||||97|61.11|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|CIGNA [1260]|CIGNA GWH [126023]|97||||97|19.82|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|97||||97|66.93|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|97||||97|21.45|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|97||||97|23.47|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|97||||97|23.47|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|97||||97|66.93|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|Self-pay|Self-pay|97||||97|33.95|66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|97||||97||66.93|19.82
30286692|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP DELTA AGENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|97||||97||66.93|19.82
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|AARP [1000]|AARP [100000]|539||||539|20.11|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|539||||539|14.53|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|AETNA [1015]|AETNA [101529]|539||||539|19.68|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|539||||539|12.09|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|539||||539|14.39|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|539||||539|14.39|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|BCBS [1155]|BCBS UTHCT [115568]|539||||539|253.33|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|539||||539|21.68|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|539||||539|269.5|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|539||||539|339.57|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|539||||539|12.09|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|539||||539|14.39|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|CIGNA [1260]|CIGNA GWH [126023]|539||||539|16.72|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|539||||539|371.91|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|539||||539|17.99|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|539||||539|14.39|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|539||||539|19.68|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|539||||539|12.09|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|539||||539|14.39|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|539||||539|19.68|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|539||||539|12.09|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|539||||539|12.09|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|539||||539|371.91|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|539||||539|12.09|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|Self-pay|Self-pay|539||||539|188.65|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|539||||539|12.09|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|539||||539|12.09|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|539||||539|20.11|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|539||||539|14.39|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|539||||539|14.39|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|539||||539|20.11|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|539||||539|14.39|371.91|12.09
30286694|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|539||||539|28.78|371.91|12.09
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|AARP [1000]|AARP [100000]|269||||269|18.43|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|269||||269|13.32|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|AETNA [1015]|AETNA [101529]|269||||269|18.05|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|269||||269|11.08|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|269||||269|13.19|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|269||||269|13.19|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|BCBS [1155]|BCBS UTHCT [115568]|269||||269|126.43|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|269||||269|19.86|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|269||||269|134.5|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|269||||269|169.47|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|269||||269|11.08|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|269||||269|13.19|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|CIGNA [1260]|CIGNA GWH [126023]|269||||269|15.29|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|269||||269|185.61|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|269||||269|16.49|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|269||||269|13.19|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|269||||269|18.05|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|269||||269|11.08|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|269||||269|13.19|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|269||||269|18.05|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|269||||269|11.08|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|269||||269|11.08|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|269||||269|185.61|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|269||||269|11.08|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|Self-pay|Self-pay|269||||269|94.15|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|269||||269|11.08|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|269||||269|11.08|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|269||||269|18.43|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|269||||269|13.19|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|269||||269|13.19|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|269||||269|18.43|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|269||||269|13.19|185.61|11.08
30286695|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|269||||269|26.38|185.61|11.08
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|AARP [1000]|AARP [100000]|285||||285|27.05|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|285||||285|19.54|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|AETNA [1015]|AETNA [101529]|285||||285|26.47|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|285||||285|16.25|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|285||||285|19.35|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|285||||285|19.35|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|BCBS [1155]|BCBS UTHCT [115568]|285||||285|133.95|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|285||||285|29.16|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|285||||285|142.5|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|285||||285|179.55|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|285||||285|16.25|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|285||||285|19.35|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|CIGNA [1260]|CIGNA GWH [126023]|285||||285|22.38|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|285||||285|196.65|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|285||||285|24.19|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|285||||285|19.35|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|285||||285|26.47|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|285||||285|16.25|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|285||||285|19.35|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|285||||285|26.47|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|285||||285|16.25|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|285||||285|16.25|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|285||||285|196.65|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|285||||285|16.25|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|Self-pay|Self-pay|285||||285|99.75|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|285||||285|16.25|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|285||||285|16.25|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|285||||285|27.05|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|285||||285|19.35|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|285||||285|19.35|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|285||||285|27.05|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|285||||285|19.35|196.65|16.25
30286696|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HERPES SIMPLEX TYPE II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|285||||285|38.7|196.65|16.25
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AARP [1000]|AARP [100000]|18||||18|17.46|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18||||18|13.93|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AETNA [1015]|AETNA [101529]|18||||18|18|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18||||18|11.58|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18||||18|13.79|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18||||18|13.79|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS [1155]|BCBS UTHCT [115568]|18||||18|8.46|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18||||18|18|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18||||18|9|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18||||18|11.34|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18||||18|11.58|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18||||18|13.79|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|CIGNA [1260]|CIGNA GWH [126023]|18||||18|14.45|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|18||||18|12.42|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18||||18|17.24|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18||||18|13.79|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18||||18|18|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18||||18|11.58|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18||||18|13.79|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18||||18|18|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18||||18|11.58|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|18||||18|11.58|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|18||||18|12.42|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18||||18|11.58|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|Self-pay|Self-pay|18||||18|6.3|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18||||18|11.58|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18||||18|11.58|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18||||18|17.46|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18||||18|13.79|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18||||18|13.79|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18||||18|17.46|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18||||18|13.79|27.58|6.3
30286698|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HISTOPLASMA AB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18||||18|27.58|27.58|6.3
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AARP [1000]|AARP [100000]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AETNA [1015]|AETNA [101529]|189||||189|12.17|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|13.38|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|10.2|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|11.11|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|12.17|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|12.17|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|Self-pay|Self-pay|189||||189|66.15|130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189||130.41|10.2
30286701|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-1|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189||130.41|10.2
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|AARP [1000]|AARP [100000]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|AETNA [1015]|AETNA [101529]|189||||189|18.5|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|20.36|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|15.58|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|16.9|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|18.5|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|18.5|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|Self-pay|Self-pay|189||||189|66.15|130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189||130.41|15.58
30286702|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HIV-2|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189||130.41|15.58
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AARP [1000]|AARP [100000]|117||||117|16.84|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|117||||117|12.17|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AETNA [1015]|AETNA [101529]|117||||117|16.49|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|117||||117|10.12|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|117||||117|12.05|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|117||||117|12.05|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|117||||117|54.99|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|117||||117|18.15|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|117||||117|58.5|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|117||||117|73.71|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|117||||117|10.12|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|117||||117|12.05|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|117||||117|13.88|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|117||||117|80.73|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|117||||117|15.06|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|117||||117|12.05|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|117||||117|16.49|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|117||||117|10.12|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|117||||117|12.05|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|117||||117|16.49|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|117||||117|10.12|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|117||||117|10.12|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|117||||117|80.73|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|117||||117|10.12|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|Self-pay|Self-pay|117||||117|40.95|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|117||||117|10.12|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|117||||117|10.12|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|117||||117|16.84|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|117||||117|12.05|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|117||||117|12.05|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|117||||117|16.84|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|117||||117|12.05|80.73|10.12
30286704|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|117||||117|24.1|80.73|10.12
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AARP [1000]|AARP [100000]|60||||60|16.44|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60||||60|11.89|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AETNA [1015]|AETNA [101529]|60||||60|16.1|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60||||60|9.89|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60||||60|11.77|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60||||60|11.77|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BCBS UTHCT [115568]|60||||60|28.2|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60||||60|17.74|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60||||60|30|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60||||60|37.8|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60||||60|9.89|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60||||60|11.77|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|CIGNA [1260]|CIGNA GWH [126023]|60||||60|13.6|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|60||||60|41.4|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|60||||60|14.71|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60||||60|11.77|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60||||60|16.1|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60||||60|9.89|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60||||60|11.77|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60||||60|16.1|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60||||60|9.89|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|60||||60|9.89|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|60||||60|41.4|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60||||60|9.89|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|Self-pay|Self-pay|60||||60|21|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|60||||60|9.89|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60||||60|9.89|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60||||60|16.44|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|60||||60|11.77|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|60||||60|11.77|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60||||60|16.44|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60||||60|11.77|41.4|9.89
30286705|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B CORE (HBCAB) IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60||||60|23.54|41.4|9.89
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AARP [1000]|AARP [100000]|169||||169|15.01|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|169||||169|10.85|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AETNA [1015]|AETNA [101529]|169||||169|14.69|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|169||||169|9.02|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|169||||169|10.74|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|169||||169|10.74|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BCBS UTHCT [115568]|169||||169|79.43|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|169||||169|16.18|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|169||||169|84.5|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|169||||169|106.47|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|169||||169|9.02|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|169||||169|10.74|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|CIGNA [1260]|CIGNA GWH [126023]|169||||169|12.47|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|169||||169|116.61|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|169||||169|13.43|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|169||||169|10.74|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|169||||169|14.69|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|169||||169|9.02|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|169||||169|10.74|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|169||||169|14.69|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|169||||169|9.02|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|169||||169|9.02|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|169||||169|116.61|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|169||||169|9.02|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|Self-pay|Self-pay|169||||169|59.15|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|169||||169|9.02|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|169||||169|9.02|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|169||||169|15.01|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|169||||169|10.74|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|169||||169|10.74|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|169||||169|15.01|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|169||||169|10.74|116.61|9.02
30286706|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP B SURFACE (HBSAB)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|169||||169|21.48|116.61|9.02
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|AARP [1000]|AARP [100000]|194||||194|16.16|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|194||||194|11.69|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|AETNA [1015]|AETNA [101529]|194||||194|15.82|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|194||||194|9.72|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|194||||194|11.57|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|194||||194|11.57|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|BCBS [1155]|BCBS UTHCT [115568]|194||||194|91.18|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|194||||194|17.42|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|194||||194|97|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|194||||194|122.22|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|194||||194|9.72|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|194||||194|11.57|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|CIGNA [1260]|CIGNA GWH [126023]|194||||194|13.32|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|194||||194|133.86|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|194||||194|14.46|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|194||||194|11.57|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|194||||194|15.82|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|194||||194|9.72|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|194||||194|11.57|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|194||||194|15.82|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|194||||194|9.72|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|194||||194|9.72|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|194||||194|133.86|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|194||||194|9.72|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|Self-pay|Self-pay|194||||194|67.9|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|194||||194|9.72|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|194||||194|9.72|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|194||||194|16.16|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|194||||194|11.57|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|194||||194|11.57|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|194||||194|16.16|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|194||||194|11.57|133.86|9.72
30286707|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP BE (HBEAB)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|194||||194|23.14|133.86|9.72
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|AARP [1000]|AARP [100000]|179||||179|17.31|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|179||||179|12.51|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|AETNA [1015]|AETNA [101529]|179||||179|16.94|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|179||||179|10.41|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|179||||179|12.39|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|179||||179|12.39|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|BCBS [1155]|BCBS UTHCT [115568]|179||||179|84.13|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|179||||179|18.65|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|179||||179|89.5|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|179||||179|112.77|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|179||||179|10.41|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|179||||179|12.39|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|CIGNA [1260]|CIGNA GWH [126023]|179||||179|14.45|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|179||||179|123.51|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|179||||179|15.49|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|179||||179|12.39|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|179||||179|16.94|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|179||||179|10.41|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|179||||179|12.39|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|179||||179|16.94|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|179||||179|10.41|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|179||||179|10.41|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|179||||179|123.51|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|179||||179|10.41|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|Self-pay|Self-pay|179||||179|62.65|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|179||||179|10.41|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|179||||179|10.41|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|179||||179|17.31|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|179||||179|12.39|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|179||||179|12.39|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|179||||179|17.31|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|179||||179|12.39|123.51|10.41
30286708|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|179||||179|24.78|123.51|10.41
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AARP [1000]|AARP [100000]|152||||152|15.73|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|152||||152|11.37|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AETNA [1015]|AETNA [101529]|152||||152|15.41|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|152||||152|9.46|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|152||||152|11.26|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|152||||152|11.26|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS [1155]|BCBS UTHCT [115568]|152||||152|71.44|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|152||||152|16.96|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|152||||152|76|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|152||||152|95.76|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|152||||152|9.46|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|152||||152|11.26|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|CIGNA [1260]|CIGNA GWH [126023]|152||||152|13.03|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|152||||152|104.88|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|152||||152|14.08|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|152||||152|11.26|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|152||||152|15.41|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|152||||152|9.46|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|152||||152|11.26|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|152||||152|15.41|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|152||||152|9.46|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|152||||152|9.46|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|152||||152|104.88|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|152||||152|9.46|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|Self-pay|Self-pay|152||||152|53.2|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|152||||152|9.46|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|152||||152|9.46|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|152||||152|15.73|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|152||||152|11.26|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|152||||152|11.26|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|152||||152|15.73|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|152||||152|11.26|104.88|9.46
30286709|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP A (HAAB) IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|152||||152|22.52|104.88|9.46
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|AARP [1000]|AARP [100000]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|AETNA [1015]|AETNA [101529]|86||||86|18.53|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|BCBS [1155]|BCBS UTHCT [115568]|86||||86|40.42|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|86||||86|20.41|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|86||||86|43|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|86||||86|54.18|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|CIGNA [1260]|CIGNA GWH [126023]|86||||86|15.86|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|GROUP PENSION ADMIN [1450]|GPA [145000]|86||||86|59.34|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|86||||86|16.94|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86||||86|18.53|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|86||||86|18.53|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|PHCS [1780]|PHCS MULTIPLAN [178000]|86||||86|59.34|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|Self-pay|Self-pay|86||||86|30.1|59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|86||||86||59.34|15.86
30286710|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB INFLUENZA TYPE A OR  B|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|86||||86||59.34|15.86
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AARP [1000]|AARP [100000]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AETNA [1015]|AETNA [101529]|126||||126|20.93|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BCBS UTHCT [115568]|126||||126|59.22|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126||||126|23.05|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126||||126|63|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126||||126|79.38|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|CIGNA [1260]|CIGNA GWH [126023]|126||||126|17.84|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126||||126|86.94|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|126||||126|19.13|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126||||126|20.93|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126||||126|20.93|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126||||126|86.94|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|Self-pay|Self-pay|126||||126|44.1|86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126||||126||86.94|17.84
30286713|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEGIONELLA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126||||126||86.94|17.84
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|AARP [1000]|AARP [100000]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|AETNA [1015]|AETNA [101529]|37||||37|22.15|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|BCBS [1155]|BCBS UTHCT [115568]|37||||37|17.39|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37||||37|19.86|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37||||37|18.5|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37||||37|23.31|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|CIGNA [1260]|CIGNA GWH [126023]|37||||37|15.29|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|37||||37|25.53|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|37||||37|20.25|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37||||37|22.15|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37||||37|22.15|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|37||||37|25.53|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|Self-pay|Self-pay|37||||37|12.95|25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37||||37||25.53|12.95
30286720|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LEPTOSPIRA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37||||37||25.53|12.95
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|AARP [1000]|AARP [100000]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|AETNA [1015]|AETNA [101529]|51||||51|17.62|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|BCBS [1155]|BCBS UTHCT [115568]|51||||51|23.97|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51||||51|19.39|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51||||51|25.5|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51||||51|32.13|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|CIGNA [1260]|CIGNA GWH [126023]|51||||51|15.02|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|51||||51|35.19|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|51||||51|16.09|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51||||51|17.62|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51||||51|17.62|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|51||||51|35.19|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|Self-pay|Self-pay|51||||51|17.85|35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51||||51||35.19|15.02
30286727|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB LYMPHOCYTIC CHORIOMENINGITIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51||||51||35.19|15.02
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AARP [1000]|AARP [100000]|56||||56|18.23|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|56||||56|13.18|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AETNA [1015]|AETNA [101529]|56||||56|17.86|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|56||||56|10.96|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|56||||56|13.05|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|56||||56|13.05|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS [1155]|BCBS UTHCT [115568]|56||||56|26.32|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|56||||56|19.65|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|56||||56|28|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|56||||56|35.28|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|56||||56|10.96|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|56||||56|13.05|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|CIGNA [1260]|CIGNA GWH [126023]|56||||56|15.29|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|56||||56|38.64|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|56||||56|16.31|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|56||||56|13.05|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|56||||56|17.86|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|56||||56|10.96|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|56||||56|13.05|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|56||||56|17.86|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|56||||56|10.96|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|56||||56|10.96|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|56||||56|38.64|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|56||||56|10.96|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|Self-pay|Self-pay|56||||56|19.6|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|56||||56|10.96|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|56||||56|10.96|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|56||||56|18.23|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|56||||56|13.05|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|56||||56|13.05|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|56||||56|18.23|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|56||||56|13.05|38.64|10.96
30286735|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MUMPS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|56||||56|26.1|38.64|10.96
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AARP [1000]|AARP [100000]|105||||105|18.51|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105||||105|13.37|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AETNA [1015]|AETNA [101529]|105||||105|18.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105||||105|11.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105||||105|13.24|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105||||105|13.24|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BCBS UTHCT [115568]|105||||105|49.35|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105||||105|19.93|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105||||105|52.5|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105||||105|66.15|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105||||105|11.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105||||105|13.24|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|CIGNA [1260]|CIGNA GWH [126023]|105||||105|15.29|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|105||||105|72.45|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105||||105|16.55|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105||||105|13.24|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105||||105|18.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105||||105|11.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105||||105|13.24|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105||||105|18.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105||||105|11.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|105||||105|11.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|105||||105|72.45|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105||||105|11.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|Self-pay|Self-pay|105||||105|36.75|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105||||105|11.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105||||105|11.12|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105||||105|18.51|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105||||105|13.24|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105||||105|13.24|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105||||105|18.51|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105||||105|13.24|72.45|11.12
30286738|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB MYCOPLASMA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105||||105|26.48|72.45|11.12
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|AARP [1000]|AARP [100000]|218||||218|21|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|218||||218|15.18|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|AETNA [1015]|AETNA [101529]|218||||218|20.57|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|218||||218|12.63|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|218||||218|15.03|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|218||||218|15.03|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|BCBS [1155]|BCBS UTHCT [115568]|218||||218|102.46|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|218||||218|22.64|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|218||||218|109|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|218||||218|137.34|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|218||||218|12.63|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|218||||218|15.03|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|CIGNA [1260]|CIGNA GWH [126023]|218||||218|17.57|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|218||||218|150.42|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|218||||218|18.79|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|218||||218|15.03|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|218||||218|20.57|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|218||||218|12.63|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|218||||218|15.03|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|218||||218|20.57|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|218||||218|12.63|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|218||||218|12.63|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|218||||218|150.42|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|218||||218|12.63|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|Self-pay|Self-pay|218||||218|76.3|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|218||||218|12.63|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|218||||218|12.63|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|218||||218|21|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|218||||218|15.03|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|218||||218|15.03|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|218||||218|21|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|218||||218|15.03|150.42|12.63
30286747|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PARVOVIRUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|218||||218|30.06|150.42|12.63
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|AARP [1000]|AARP [100000]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|AETNA [1015]|AETNA [101529]|24||||24|16.94|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|BCBS [1155]|BCBS UTHCT [115568]|24||||24|11.28|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24||||24|18.65|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24||||24|12|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24||||24|15.12|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|CIGNA [1260]|CIGNA GWH [126023]|24||||24|14.45|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|24||||24|16.56|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24||||24|15.49|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24||||24|16.94|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24||||24|16.94|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|24||||24|16.56|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|Self-pay|Self-pay|24||||24|8.4|18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24||||24||18.65|8.4
30286753|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB PROTOZOA AMOEBIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24||||24||18.65|8.4
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|AARP [1000]|AARP [100000]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|AETNA [1015]|AETNA [101529]|1505||||1505|26.47|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|BCBS [1155]|BCBS UTHCT [115568]|1505||||1505|707.35|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1505||||1505|29.16|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1505||||1505|752.5|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1505||||1505|948.15|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|CIGNA [1260]|CIGNA GWH [126023]|1505||||1505|22.38|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1505||||1505|1038.45|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1505||||1505|24.19|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1505||||1505|26.47|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1505||||1505|26.47|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1505||||1505|1038.45|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|Self-pay|Self-pay|1505||||1505|526.75|1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1505||||1505||1038.45|22.38
30286757|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RICKETTSIA AB QL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1505||||1505||1038.45|22.38
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|AARP [1000]|AARP [100000]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|AETNA [1015]|AETNA [101529]|72||||72|19.68|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|BCBS [1155]|BCBS UTHCT [115568]|72||||72|33.84|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72||||72|21.68|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72||||72|36|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72||||72|45.36|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|CIGNA [1260]|CIGNA GWH [126023]|72||||72|16.72|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|72||||72|49.68|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|72||||72|17.99|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72||||72|19.68|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72||||72|19.68|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|72||||72|49.68|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|Self-pay|Self-pay|72||||72|25.2|49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72||||72||49.68|16.72
30286762|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBELLA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72||||72||49.68|16.72
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|AARP [1000]|AARP [100000]|80||||80|18|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|80||||80|13.01|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|AETNA [1015]|AETNA [101529]|80||||80|17.62|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|80||||80|10.82|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|80||||80|12.88|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|80||||80|12.88|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|BCBS [1155]|BCBS UTHCT [115568]|80||||80|37.6|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|80||||80|19.4|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|80||||80|40|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|80||||80|50.4|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|80||||80|10.82|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|80||||80|12.88|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|CIGNA [1260]|CIGNA GWH [126023]|80||||80|15.02|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|80||||80|55.2|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|80||||80|16.1|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|80||||80|12.88|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|80||||80|17.62|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|80||||80|10.82|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|80||||80|12.88|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|80||||80|17.62|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|80||||80|10.82|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|80||||80|10.82|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|80||||80|55.2|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|80||||80|10.82|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|Self-pay|Self-pay|80||||80|28|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|80||||80|10.82|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|80||||80|10.82|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|80||||80|18|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|80||||80|12.88|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|80||||80|12.88|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|80||||80|18|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|80||||80|12.88|55.2|10.82
30286765|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB RUBEOLA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|80||||80|25.76|55.2|10.82
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|AARP [1000]|AARP [100000]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84.26||||84.26|42.55|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|AETNA [1015]|AETNA [101529]|84.26||||84.26|84.26|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|BCBS [1155]|BCBS UTHCT [115568]|84.26||||84.26|39.6|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84.26||||84.26|51.4|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84.26||||84.26|53.08|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|CIGNA [1260]|CIGNA GWH [126023]|84.26||||84.26|46.34|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|84.26||||84.26|58.14|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|84.26||||84.26|54.76|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84.26||||84.26|84.26|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84.26||||84.26|84.26|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|84.26||||84.26|58.14|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|Self-pay|Self-pay|84.26||||84.26|29.49|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84.26||||84.26|42.13|84.26|29.49
30286769|EAP|0302 - LABORATORY-IMMUNOLOGY|HC SARS-COV-2 COVID-19 ANTIBODY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84.26||||84.26|84.26|84.26|29.49
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|AARP [1000]|AARP [100000]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|AETNA [1015]|AETNA [101529]|28||||28|19.7|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|BCBS [1155]|BCBS UTHCT [115568]|28||||28|13.16|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28||||28|21.69|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28||||28|14|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28||||28|17.64|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|CIGNA [1260]|CIGNA GWH [126023]|28||||28|16.72|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|28||||28|19.32|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|28||||28|18.01|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28||||28|19.7|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28||||28|19.7|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|28||||28|19.32|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|Self-pay|Self-pay|28||||28|9.8|21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28||||28||21.69|9.8
30286778|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB TOXOPLASMA IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28||||28||21.69|9.8
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|AARP [1000]|AARP [100000]|115||||115|18.97|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|115||||115|13.37|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|AETNA [1015]|AETNA [101529]|115||||115|18.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|115||||115|11.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|115||||115|13.24|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|115||||115|13.24|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|BCBS [1155]|BCBS UTHCT [115568]|115||||115|54.05|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|115||||115|19.93|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|115||||115|57.5|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|115||||115|72.45|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|115||||115|11.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|115||||115|13.24|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|CIGNA [1260]|CIGNA GWH [126023]|115||||115|63.25|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|115||||115|79.35|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|115||||115|16.55|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|115||||115|13.24|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|115||||115|18.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|115||||115|11.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|115||||115|13.24|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|115||||115|18.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|115||||115|11.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|115||||115|11.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|115||||115|79.35|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|115||||115|11.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|Self-pay|Self-pay|115||||115|40.25|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|115||||115|11.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|115||||115|11.12|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|115||||115|18.97|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|115||||115|13.24|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|115||||115|13.24|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|115||||115|18.97|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|115||||115|13.24|79.35|11.12
30286780|EAP|0302 - LABORATORY-IMMUNOLOGY|HC ANTIBODY TREPONEMA PALLIDUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|115||||115|26.48|79.35|11.12
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|AARP [1000]|AARP [100000]|239||||239|18|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|239||||239|13.01|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|AETNA [1015]|AETNA [101529]|239||||239|17.62|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|239||||239|10.82|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|239||||239|12.88|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|239||||239|12.88|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|BCBS [1155]|BCBS UTHCT [115568]|239||||239|112.33|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|239||||239|19.4|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|239||||239|119.5|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|239||||239|150.57|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|239||||239|10.82|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|239||||239|12.88|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|CIGNA [1260]|CIGNA GWH [126023]|239||||239|15.02|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|239||||239|164.91|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|239||||239|16.1|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|239||||239|12.88|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|239||||239|17.62|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|239||||239|10.82|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|239||||239|12.88|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|239||||239|17.62|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|239||||239|10.82|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|239||||239|10.82|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|239||||239|164.91|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|239||||239|10.82|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|Self-pay|Self-pay|239||||239|83.65|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|239||||239|10.82|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|239||||239|10.82|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|239||||239|18|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|239||||239|12.88|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|239||||239|12.88|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|239||||239|18|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|239||||239|12.88|164.91|10.82
30286787|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VARICELLA ZOSTER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|239||||239|25.76|164.91|10.82
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|AARP [1000]|AARP [100000]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|AETNA [1015]|AETNA [101529]|161||||161|23.04|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|BCBS [1155]|BCBS UTHCT [115568]|161||||161|75.67|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161||||161|25.38|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161||||161|80.5|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161||||161|101.43|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|CIGNA [1260]|CIGNA GWH [126023]|161||||161|19.54|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|161||||161|111.09|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|161||||161|21.06|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161||||161|23.04|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161||||161|23.04|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|161||||161|111.09|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|Self-pay|Self-pay|161||||161|56.35|111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161||||161||111.09|19.54
30286788|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB IGM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161||||161||111.09|19.54
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|AARP [1000]|AARP [100000]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|AETNA [1015]|AETNA [101529]|161||||161|19.68|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|BCBS [1155]|BCBS UTHCT [115568]|161||||161|75.67|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161||||161|21.68|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161||||161|80.5|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161||||161|101.43|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|CIGNA [1260]|CIGNA GWH [126023]|161||||161|16.72|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|161||||161|111.09|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|161||||161|17.99|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161||||161|19.68|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161||||161|19.68|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|161||||161|111.09|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|Self-pay|Self-pay|161||||161|56.35|111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161||||161||111.09|16.72
30286789|EAP|0302 - LABORATORY-IMMUNOLOGY|HC WEST NILE VIRUS AB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161||||161||111.09|16.72
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|AARP [1000]|AARP [100000]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|AETNA [1015]|AETNA [101529]|126||||126|17.62|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|BCBS [1155]|BCBS UTHCT [115568]|126||||126|59.22|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126||||126|19.4|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126||||126|63|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126||||126|79.38|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|CIGNA [1260]|CIGNA GWH [126023]|126||||126|15.02|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126||||126|86.94|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|126||||126|16.1|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126||||126|17.62|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126||||126|17.62|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126||||126|86.94|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|Self-pay|Self-pay|126||||126|44.1|86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126||||126||86.94|15.02
30286790|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB VIRUS NOT SPECIFIED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126||||126||86.94|15.02
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|AARP [1000]|AARP [100000]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|AETNA [1015]|AETNA [101529]|54||||54|18.05|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|BCBS [1155]|BCBS UTHCT [115568]|54||||54|25.38|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54||||54|19.86|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54||||54|27|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54||||54|34.02|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|CIGNA [1260]|CIGNA GWH [126023]|54||||54|15.29|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54||||54|37.26|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54||||54|16.49|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54||||54|18.05|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54||||54|18.05|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54||||54|37.26|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|Self-pay|Self-pay|54||||54|18.9|37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54||||54||37.26|15.29
30286793|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB YERSINIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54||||54||37.26|15.29
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AARP [1000]|AARP [100000]|72||||72|22.22|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72||||72|16.07|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AETNA [1015]|AETNA [101529]|72||||72|21.77|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72||||72|13.36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72||||72|15.91|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72||||72|15.91|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS [1155]|BCBS UTHCT [115568]|72||||72|33.84|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72||||72|23.96|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72||||72|36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72||||72|45.36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72||||72|13.36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72||||72|15.91|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|CIGNA [1260]|CIGNA GWH [126023]|72||||72|18.42|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|72||||72|49.68|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|72||||72|19.89|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72||||72|15.91|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72||||72|21.77|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72||||72|13.36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72||||72|15.91|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72||||72|21.77|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72||||72|13.36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|72||||72|13.36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|72||||72|49.68|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72||||72|13.36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|Self-pay|Self-pay|72||||72|25.2|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|72||||72|13.36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72||||72|13.36|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72||||72|22.22|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|72||||72|15.91|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|72||||72|15.91|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72||||72|22.22|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72||||72|15.91|49.68|13.36
30286800|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB THYROGLOBULIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72||||72|31.82|49.68|13.36
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AARP [1000]|AARP [100000]|209||||209|19.94|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|209||||209|14.41|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AETNA [1015]|AETNA [101529]|209||||209|19.51|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|209||||209|11.99|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|209||||209|14.27|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|209||||209|14.27|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS [1155]|BCBS UTHCT [115568]|209||||209|98.23|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|209||||209|21.48|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|209||||209|104.5|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|209||||209|131.67|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|209||||209|11.99|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|209||||209|14.27|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|CIGNA [1260]|CIGNA GWH [126023]|209||||209|16.72|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|209||||209|144.21|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|209||||209|17.84|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|209||||209|14.27|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|209||||209|19.51|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|209||||209|11.99|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|209||||209|14.27|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|209||||209|19.51|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|209||||209|11.99|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|209||||209|11.99|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|209||||209|144.21|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|209||||209|11.99|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|Self-pay|Self-pay|209||||209|73.15|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|209||||209|11.99|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|209||||209|11.99|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|209||||209|19.94|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|209||||209|14.27|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|209||||209|14.27|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|209||||209|19.94|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|209||||209|14.27|144.21|11.99
30286803|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AB HEP C|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|209||||209|28.54|144.21|11.99
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|AARP [1000]|AARP [100000]|343||||343|36.06|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|343||||343|26.07|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|AETNA [1015]|AETNA [101529]|343||||343|35.3|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|343||||343|21.68|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|343||||343|25.81|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|343||||343|25.81|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|BCBS [1155]|BCBS UTHCT [115568]|343||||343|161.21|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|343||||343|38.87|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|343||||343|171.5|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|343||||343|216.09|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|343||||343|21.68|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|343||||343|25.81|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|CIGNA [1260]|CIGNA GWH [126023]|343||||343|30.02|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|343||||343|236.67|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|343||||343|32.26|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|343||||343|25.81|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|343||||343|35.3|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|343||||343|21.68|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|343||||343|25.81|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|343||||343|35.3|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|343||||343|21.68|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|343||||343|21.68|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|343||||343|236.67|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|343||||343|21.68|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|Self-pay|Self-pay|343||||343|120.05|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|343||||343|21.68|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|343||||343|21.68|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|343||||343|36.06|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|343||||343|25.81|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|343||||343|25.81|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|343||||343|36.06|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|343||||343|25.81|236.67|21.68
30286812|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA TYPING SINGLE AG A/B/C|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|343||||343|51.62|236.67|21.68
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|AARP [1000]|AARP [100000]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|AETNA [1015]|AETNA [101529]|417||||417|130.68|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|BCBS [1155]|BCBS UTHCT [115568]|417||||417|195.99|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|417||||417|121.61|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|417||||417|208.5|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|417||||417|262.71|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|CIGNA [1260]|CIGNA GWH [126023]|417||||417|229.35|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|417||||417|287.73|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|417||||417|119.4|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|417||||417|130.68|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|417||||417|130.68|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|417||||417|287.73|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|Self-pay|Self-pay|417||||417|145.95|287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|417||||417||287.73|119.4
30286830|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HLA CLASS I PHENOTYPE QUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|417||||417||287.73|119.4
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|AARP [1000]|AARP [100000]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|AETNA [1015]|AETNA [101529]|189||||189|13.37|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189|56.04|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|54.53|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189|56.04|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|12.18|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|62.2|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|13.37|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189|56.04|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|13.37|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189|56.04|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189|56.04|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189|56.04|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|Self-pay|Self-pay|189||||189|66.15|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189|56.04|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189|56.04|130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189||130.41|12.18
30286850|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189||130.41|12.18
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|AARP [1000]|AARP [100000]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|AETNA [1015]|AETNA [101529]|135||||135|45.82|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135||||135|40.03|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|BCBS [1155]|BCBS UTHCT [115568]|135||||135|63.45|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135||||135|135|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135||||135|67.5|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135||||135|85.05|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135||||135|40.03|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|CIGNA [1260]|CIGNA GWH [126023]|135||||135|14.74|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|135||||135|93.15|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|135||||135|186.45|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135||||135|45.82|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135||||135|40.03|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135||||135|45.82|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135||||135|40.03|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|135||||135|40.03|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|135||||135|93.15|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135||||135|40.03|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|Self-pay|Self-pay|135||||135|47.25|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|135||||135|40.03|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135||||135|40.03|186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135||||135||186.45|14.74
30286860|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ELUTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135||||135||186.45|14.74
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AARP [1000]|AARP [100000]|277||||277|20.43|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277||||277|266.76|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AETNA [1015]|AETNA [101529]|277||||277|62.95|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277||||277|82.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277||||277|264.12|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277||||277|264.12|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS [1155]|BCBS UTHCT [115568]|277||||277|130.19|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277||||277|262.82|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277||||277|138.5|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277||||277|174.51|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277||||277|82.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277||||277|264.12|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|CIGNA [1260]|CIGNA GWH [126023]|277||||277|22.67|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277||||277|191.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|277||||277|364.08|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277||||277|282.87|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277||||277|62.95|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277||||277|82.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277||||277|264.12|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277||||277|62.95|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277||||277|82.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|277||||277|82.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277||||277|191.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277||||277|82.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|Self-pay|Self-pay|277||||277|96.95|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|277||||277|82.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277||||277|82.13|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277||||277|20.43|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|277||||277|264.12|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|277||||277|264.12|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277||||277|20.43|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277||||277|264.12|528.23|20.43
30286870|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB IDENTIFICATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277||||277|528.23|528.23|20.43
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AARP [1000]|AARP [100000]|133||||133|7.5|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|133||||133|50.97|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AETNA [1015]|AETNA [101529]|133||||133|7.37|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|133||||133|4.53|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|133||||133|50.47|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|133||||133|50.47|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BCBS UTHCT [115568]|133||||133|62.51|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|133||||133|38.8|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|133||||133|66.5|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|133||||133|83.79|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|133||||133|4.53|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|133||||133|50.47|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|CIGNA [1260]|CIGNA GWH [126023]|133||||133|6.24|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|133||||133|91.77|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|133||||133|69.58|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|133||||133|54.05|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|133||||133|7.37|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|133||||133|4.53|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|133||||133|50.47|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|133||||133|7.37|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|133||||133|4.53|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|133||||133|4.53|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|133||||133|91.77|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|133||||133|4.53|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|Self-pay|Self-pay|133||||133|46.55|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|133||||133|4.53|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|133||||133|4.53|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|133||||133|7.5|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|133||||133|50.47|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|133||||133|50.47|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|133||||133|7.5|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|133||||133|50.47|100.94|4.53
30286880|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS DIRECT IGG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|133||||133|100.94|100.94|4.53
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AARP [1000]|AARP [100000]|111||||111|7.99|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111||||111|136.61|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AETNA [1015]|AETNA [101529]|111||||111|7.82|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111||||111|4.8|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111||||111|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111||||111|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BCBS UTHCT [115568]|111||||111|52.17|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111||||111|111|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111||||111|55.5|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111||||111|69.93|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111||||111|4.8|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111||||111|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|CIGNA [1260]|CIGNA GWH [126023]|111||||111|6.5|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|111||||111|76.59|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|111||||111|186.45|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111||||111|144.86|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111||||111|7.82|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111||||111|4.8|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111||||111|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111||||111|7.82|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111||||111|4.8|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|111||||111|4.8|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|111||||111|76.59|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111||||111|4.8|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|Self-pay|Self-pay|111||||111|38.85|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|111||||111|4.8|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111||||111|4.8|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111||||111|7.99|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|111||||111|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|111||||111|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111||||111|7.99|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111||||111|135.26|270.52|4.8
30286885|EAP|0302 - LABORATORY-IMMUNOLOGY|HC AG PAT TESTING INDIRECT QUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111||||111|270.52|270.52|4.8
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AARP [1000]|AARP [100000]|499||||499|7.23|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|499||||499|136.61|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AETNA [1015]|AETNA [101529]|499||||499|7.08|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|499||||499|4.35|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|499||||499|135.26|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|499||||499|135.26|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BCBS UTHCT [115568]|499||||499|234.53|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|499||||499|157.6|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|499||||499|249.5|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|499||||499|314.37|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|499||||499|4.35|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|499||||499|135.26|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|CIGNA [1260]|CIGNA GWH [126023]|499||||499|5.95|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|499||||499|344.31|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|499||||499|186.45|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|499||||499|144.86|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|499||||499|7.08|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|499||||499|4.35|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|499||||499|135.26|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|499||||499|7.08|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|499||||499|4.35|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|499||||499|4.35|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|499||||499|344.31|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|499||||499|4.35|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|Self-pay|Self-pay|499||||499|174.65|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|499||||499|4.35|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|499||||499|4.35|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|499||||499|7.23|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|499||||499|135.26|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|499||||499|135.26|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|499||||499|7.23|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|499||||499|135.26|344.31|4.35
30286886|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COOMBS INDIRECT EACH AB TITER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|499||||499|270.52|344.31|4.35
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AARP [1000]|AARP [100000]|207||||207|4.17|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|207||||207|102.53|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AETNA [1015]|AETNA [101529]|207||||207|4.08|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|207||||207|2.51|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|207||||207|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|207||||207|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BCBS UTHCT [115568]|207||||207|97.29|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|207||||207|128.15|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|207||||207|103.5|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|207||||207|130.41|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|207||||207|2.51|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|207||||207|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|CIGNA [1260]|CIGNA GWH [126023]|207||||207|3.4|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|207||||207|142.83|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|207||||207|139.94|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|207||||207|108.73|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|207||||207|4.08|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|207||||207|2.51|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|207||||207|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|207||||207|4.08|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|207||||207|2.51|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|207||||207|2.51|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|207||||207|142.83|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|207||||207|2.51|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|Self-pay|Self-pay|207||||207|72.45|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|207||||207|2.51|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|207||||207|2.51|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|207||||207|4.17|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|207||||207|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|207||||207|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|207||||207|4.17|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|207||||207|101.52|203.04|2.51
30286900|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING ABO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|207||||207|203.04|203.04|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AARP [1000]|AARP [100000]|207||||207|7.25|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|207||||207|30.99|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AETNA [1015]|AETNA [101529]|207||||207|4.08|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|207||||207|2.51|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|207||||207|30.69|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|207||||207|30.69|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BCBS UTHCT [115568]|207||||207|97.29|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|207||||207|38.8|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|207||||207|103.5|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|207||||207|130.41|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|207||||207|2.51|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|207||||207|30.69|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|CIGNA [1260]|CIGNA GWH [126023]|207||||207|3.4|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|207||||207|142.83|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|207||||207|42.3|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|207||||207|32.86|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|207||||207|4.08|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|207||||207|2.51|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|207||||207|30.69|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|207||||207|4.08|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|207||||207|2.51|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|207||||207|2.51|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|207||||207|142.83|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|207||||207|2.51|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|Self-pay|Self-pay|207||||207|72.45|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|207||||207|2.51|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|207||||207|2.51|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|207||||207|7.25|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|207||||207|30.69|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|207||||207|30.69|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|207||||207|7.25|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|207||||207|30.69|142.83|2.51
30286901|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD TYPING RH (D)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|207||||207|61.37|142.83|2.51
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AARP [1000]|AARP [100000]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AETNA [1015]|AETNA [101529]|118||||118|8.69|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS [1155]|BCBS UTHCT [115568]|118||||118|55.46|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|118||||118|118|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|118||||118|59|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|118||||118|74.34|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|CIGNA [1260]|CIGNA GWH [126023]|118||||118|64.9|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|118||||118|81.42|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|118||||118|364.08|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|118||||118|8.69|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|118||||118|8.69|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|118||||118|81.42|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|Self-pay|Self-pay|118||||118|41.3|364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|118||||118||364.08|8.69
30286902|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLOOD TYPE ANTIGEN DONOR REAGENT SERUM EA AG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|118||||118||364.08|8.69
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AARP [1000]|AARP [100000]|340||||340|20.43|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|340||||340|136.61|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AETNA [1015]|AETNA [101529]|340||||340|50.86|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|340||||340|100.81|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|340||||340|135.26|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|340||||340|135.26|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BCBS UTHCT [115568]|340||||340|159.8|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|340||||340|157.6|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|340||||340|170|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|340||||340|214.2|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|340||||340|100.81|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|340||||340|135.26|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|CIGNA [1260]|CIGNA GWH [126023]|340||||340|20.11|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|340||||340|234.6|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|340||||340|186.45|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|340||||340|144.86|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|340||||340|50.86|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|340||||340|100.81|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|340||||340|135.26|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|340||||340|50.86|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|340||||340|100.81|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|340||||340|100.81|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|340||||340|234.6|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|340||||340|100.81|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|Self-pay|Self-pay|340||||340|119|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|340||||340|100.81|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|340||||340|100.81|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|340||||340|20.43|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|340||||340|135.26|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|340||||340|135.26|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|340||||340|20.43|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|340||||340|135.26|270.52|20.11
30286920|EAP|0302 - LABORATORY-IMMUNOLOGY|HC CROSSMATCH IMMEDIAT SPIN AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|340||||340|270.52|270.52|20.11
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|AARP [1000]|AARP [100000]|139||||139|20.43|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139||||139|136.61|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|AETNA [1015]|AETNA [101529]|139||||139|54.38|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139||||139|41.21|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139||||139|135.26|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139||||139|135.26|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|BCBS [1155]|BCBS UTHCT [115568]|139||||139|65.33|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139||||139|139|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139||||139|69.5|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139||||139|87.57|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139||||139|41.21|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139||||139|135.26|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|CIGNA [1260]|CIGNA GWH [126023]|139||||139|18.42|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|139||||139|95.91|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|139||||139|186.45|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139||||139|144.86|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139||||139|54.38|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139||||139|41.21|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139||||139|135.26|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139||||139|54.38|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139||||139|41.21|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|139||||139|41.21|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|139||||139|95.91|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139||||139|41.21|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|Self-pay|Self-pay|139||||139|48.65|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|139||||139|41.21|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139||||139|41.21|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139||||139|20.43|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|139||||139|135.26|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|139||||139|135.26|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139||||139|20.43|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139||||139|135.26|270.52|18.42
30286922|EAP|0302 - LABORATORY-IMMUNOLOGY|HC REF LAB SPEC ARC CHG-AGT XM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139||||139|270.52|270.52|18.42
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AARP [1000]|AARP [100000]|432||||432|21.98|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|432||||432|136.61|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AETNA [1015]|AETNA [101529]|432||||432|40.8|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|432||||432|128.09|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|432||||432|135.26|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|432||||432|135.26|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BCBS UTHCT [115568]|432||||432|203.04|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|432||||432|157.6|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|432||||432|216|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|432||||432|272.16|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|432||||432|128.09|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|432||||432|135.26|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|CIGNA [1260]|CIGNA GWH [126023]|432||||432|14.74|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|432||||432|298.08|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|432||||432|186.45|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|432||||432|144.86|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|432||||432|40.8|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|432||||432|128.09|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|432||||432|135.26|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|432||||432|40.8|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|432||||432|128.09|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|432||||432|128.09|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|432||||432|298.08|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|432||||432|128.09|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|Self-pay|Self-pay|432||||432|151.2|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|432||||432|128.09|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|432||||432|128.09|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|432||||432|21.98|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|432||||432|135.26|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|432||||432|135.26|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|432||||432|21.98|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|432||||432|135.26|298.08|14.74
30286923|EAP|0302 - LABORATORY-IMMUNOLOGY|HC COMPAT TEST EACH UNIT ELECT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|432||||432|270.52|298.08|14.74
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|AARP [1000]|AARP [100000]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|AETNA [1015]|AETNA [101529]|99||||99|28.7|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99||||99|29.35|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|BCBS [1155]|BCBS UTHCT [115568]|99||||99|46.53|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99||||99|15.76|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99||||99|49.5|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99||||99|62.37|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99||||99|29.35|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|CIGNA [1260]|CIGNA GWH [126023]|99||||99|7.93|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|99||||99|68.31|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|99||||99|186.45|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99||||99|28.7|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99||||99|29.35|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99||||99|28.7|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99||||99|29.35|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|99||||99|29.35|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|99||||99|68.31|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99||||99|29.35|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|Self-pay|Self-pay|99||||99|34.65|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|99||||99|29.35|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99||||99|29.35|186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99||||99||186.45|7.93
30286927|EAP|0302 - LABORATORY-IMMUNOLOGY|HC FRESH FROZEN PLASMA THAWING EACH UNIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99||||99||186.45|7.93
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|AARP [1000]|AARP [100000]|160||||160|16.92|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|160||||160|12.23|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|AETNA [1015]|AETNA [101529]|160||||160|16.56|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|160||||160|10.17|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|160||||160|12.11|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|160||||160|12.11|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|BCBS [1155]|BCBS UTHCT [115568]|160||||160|75.2|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|160||||160|18.24|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|160||||160|80|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|160||||160|100.8|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|160||||160|10.17|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|160||||160|12.11|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|CIGNA [1260]|CIGNA GWH [126023]|160||||160|14.17|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|160||||160|110.4|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|160||||160|80|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|160||||160|12.11|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|160||||160|16.56|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|160||||160|10.17|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|160||||160|12.11|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|160||||160|16.56|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|160||||160|10.17|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|160||||160|10.17|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|160||||160|110.4|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|160||||160|10.17|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|Self-pay|Self-pay|160||||160|56|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|160||||160|10.17|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|160||||160|10.17|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|160||||160|16.92|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|160||||160|12.11|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|160||||160|12.11|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|160||||160|16.92|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|160||||160|12.11|110.4|10.17
30286941|EAP|0302 - LABORATORY-IMMUNOLOGY|HC HEMOLYSINS&AGGLUTININS INCUBATED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|160||||160|24.22|110.4|10.17
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|AARP [1000]|AARP [100000]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|AETNA [1015]|AETNA [101529]|70||||70|42.31|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70||||70|20.76|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|BCBS [1155]|BCBS UTHCT [115568]|70||||70|32.9|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70||||70|38.8|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70||||70|35|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70||||70|44.1|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70||||70|20.76|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|CIGNA [1260]|CIGNA GWH [126023]|70||||70|16.99|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70||||70|48.3|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70||||70|42.3|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70||||70|42.31|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70||||70|20.76|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70||||70|42.31|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70||||70|20.76|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70||||70|20.76|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70||||70|48.3|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70||||70|20.76|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|Self-pay|Self-pay|70||||70|24.5|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70||||70|20.76|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70||||70|20.76|48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70||||70||48.3|16.99
30286945|EAP|0302 - LABORATORY-IMMUNOLOGY|HC BLD PRODUCT IRRADIATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70||||70||48.3|16.99
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|AARP [1000]|AARP [100000]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|AETNA [1015]|AETNA [101529]|114||||114|33.74|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|114||||114|33.8|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|BCBS [1155]|BCBS UTHCT [115568]|114||||114|53.58|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|114||||114|114|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|114||||114|57|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|114||||114|71.82|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|114||||114|33.8|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|CIGNA [1260]|CIGNA GWH [126023]|114||||114|12.18|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|114||||114|78.66|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|114||||114|364.08|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|114||||114|33.74|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|114||||114|33.8|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|114||||114|33.74|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|114||||114|33.8|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|114||||114|33.8|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|114||||114|78.66|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|114||||114|33.8|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|Self-pay|Self-pay|114||||114|39.9|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|114||||114|33.8|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|114||||114|33.8|364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|114||||114||364.08|12.18
30286971|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT INCUB W/ ENZYMES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|114||||114||364.08|12.18
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|AARP [1000]|AARP [100000]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|AETNA [1015]|AETNA [101529]|432||||432|59.42|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|432||||432|128.09|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|BCBS [1155]|BCBS UTHCT [115568]|432||||432|203.04|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|432||||432|157.6|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|432||||432|216|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|432||||432|272.16|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|432||||432|128.09|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|CIGNA [1260]|CIGNA GWH [126023]|432||||432|19.54|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|432||||432|298.08|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|432||||432|186.45|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|432||||432|59.42|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|432||||432|128.09|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|432||||432|59.42|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|432||||432|128.09|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|432||||432|128.09|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|432||||432|298.08|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|432||||432|128.09|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|Self-pay|Self-pay|432||||432|151.2|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|432||||432|128.09|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|432||||432|128.09|298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|432||||432||298.08|19.54
30286972|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC PRTRMNT DENSITY GRAD SEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|432||||432||298.08|19.54
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|AARP [1000]|AARP [100000]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|AETNA [1015]|AETNA [101529]|83||||83|50.86|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83||||83|24.61|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|BCBS [1155]|BCBS UTHCT [115568]|83||||83|39.01|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83||||83|83|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83||||83|41.5|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83||||83|52.29|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83||||83|24.61|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|CIGNA [1260]|CIGNA GWH [126023]|83||||83|16.43|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|83||||83|57.27|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|83||||83|186.45|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83||||83|50.86|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83||||83|24.61|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83||||83|50.86|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83||||83|24.61|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|83||||83|24.61|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|83||||83|57.27|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83||||83|24.61|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|Self-pay|Self-pay|83||||83|29.05|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|83||||83|24.61|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83||||83|24.61|186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83||||83||186.45|16.43
30286977|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC SERUM PRETX INCUB INHIB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83||||83||186.45|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|AARP [1000]|AARP [100000]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|AETNA [1015]|AETNA [101529]|70||||70|50.86|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70||||70|20.76|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|BCBS [1155]|BCBS UTHCT [115568]|70||||70|32.9|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70||||70|38.8|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70||||70|35|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70||||70|44.1|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70||||70|20.76|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|CIGNA [1260]|CIGNA GWH [126023]|70||||70|16.43|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70||||70|48.3|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70||||70|42.3|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70||||70|50.86|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70||||70|20.76|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70||||70|50.86|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70||||70|20.76|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70||||70|20.76|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70||||70|48.3|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70||||70|20.76|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|Self-pay|Self-pay|70||||70|24.5|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70||||70|20.76|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70||||70|20.76|50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70||||70||50.86|16.43
30286978|EAP|0302 - LABORATORY-IMMUNOLOGY|HC RBC AB ID ABSORPT DIFFERENTL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70||||70||50.86|16.43
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|13.85||||13.85|6.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.85||||13.85|4.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|13.85||||13.85|6.51|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.85||||13.85|6.93|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.85||||13.85|6.93|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.85||||13.85|8.73|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.85||||13.85|4.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|13.85||||13.85|7.62|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|13.85||||13.85|9.56|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.85||||13.85|6.93|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.85||||13.85|6.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.85||||13.85|4.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.85||||13.85|6.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.85||||13.85|4.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.85||||13.85|4.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|13.85||||13.85|9.56|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.85||||13.85|4.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|Self-pay|Self-pay|13.85||||13.85|4.85|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.85||||13.85|4.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.85||||13.85|4.11|9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.85||||13.85||9.56|4.11
30433|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DROSPIRENONE 3 MG-ETHINYL ESTRADIOL 0.03 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.85||||13.85||9.56|4.11
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|AARP [1000]|AARP [100000]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|AETNA [1015]|AETNA [101529]|10.27||||10.27|4.53|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.27||||10.27|3.05|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|BCBS [1155]|BCBS UTHCT [115568]|10.27||||10.27|4.83|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.27||||10.27|5.14|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.27||||10.27|5.14|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.27||||10.27|6.47|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.27||||10.27|3.05|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|CIGNA [1260]|CIGNA GWH [126023]|10.27||||10.27|5.65|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.27||||10.27|7.09|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.27||||10.27|5.14|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.27||||10.27|4.53|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.27||||10.27|3.05|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.27||||10.27|4.53|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.27||||10.27|3.05|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.27||||10.27|3.05|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.27||||10.27|7.09|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.27||||10.27|3.05|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|Self-pay|Self-pay|10.27||||10.27|3.59|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.27||||10.27|3.05|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.27||||10.27|3.05|7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.27||||10.27||7.09|3.05
30479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXCARBAZEPINE 300 MG/5 ML (60 MG/ML) ORAL SUSPENSION REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.27||||10.27||7.09|3.05
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|AARP [1000]|AARP [100000]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|AETNA [1015]|AETNA [101529]|65||||65|24.7|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65||||65|19.27|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|BCBS [1155]|BCBS UTHCT [115568]|65||||65|30.55|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65||||65|23.96|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65||||65|32.5|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65||||65|40.95|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65||||65|19.27|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|CIGNA [1260]|CIGNA GWH [126023]|65||||65|35.75|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|65||||65|44.85|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65||||65|22.56|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65||||65|24.7|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65||||65|19.27|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65||||65|24.7|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65||||65|19.27|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|65||||65|19.27|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|65||||65|44.85|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65||||65|19.27|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|Self-pay|Self-pay|65||||65|22.75|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65||||65|19.27|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65||||65|19.27|44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65||||65||44.85|19.27
30500328|EAP|0305 - LABORATORY-HEMATOLOGY|HC FECAL BLOOD SCRN IMMUNOASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65||||65||44.85|19.27
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AARP [1000]|AARP [100000]|78||||78|4.81|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|78||||78|3.84|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AETNA [1015]|AETNA [101529]|78||||78|5.21|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|78||||78|3.19|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|78||||78|3.8|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|78||||78|3.8|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BCBS UTHCT [115568]|78||||78|36.66|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|78||||78|5.17|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|78||||78|39|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|78||||78|49.14|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|78||||78|3.19|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|78||||78|3.8|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|CIGNA [1260]|CIGNA GWH [126023]|78||||78|6.35|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|78||||78|53.82|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|78||||78|4.75|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|78||||78|3.8|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|78||||78|5.21|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|78||||78|3.19|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|78||||78|3.8|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|78||||78|5.21|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|78||||78|3.19|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|78||||78|3.19|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|78||||78|53.82|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|78||||78|3.19|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|Self-pay|Self-pay|78||||78|27.3|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|78||||78|3.19|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|78||||78|3.19|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|78||||78|4.81|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|78||||78|3.8|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|78||||78|3.8|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|78||||78|4.81|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|78||||78|3.8|53.82|3.19
30585007|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD DIFFERENTIAL WBC MANUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|78||||78|7.6|53.82|3.19
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AARP [1000]|AARP [100000]|59||||59|3.31|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59||||59|2.39|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AETNA [1015]|AETNA [101529]|59||||59|3.24|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59||||59|1.99|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59||||59|2.37|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59||||59|2.37|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BCBS UTHCT [115568]|59||||59|27.73|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59||||59|3.57|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59||||59|29.5|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59||||59|37.17|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59||||59|1.99|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59||||59|2.37|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|CIGNA [1260]|CIGNA GWH [126023]|59||||59|4.54|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|59||||59|40.71|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|59||||59|2.96|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59||||59|2.37|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59||||59|3.24|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59||||59|1.99|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59||||59|2.37|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59||||59|3.24|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59||||59|1.99|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|59||||59|1.99|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|59||||59|40.71|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59||||59|1.99|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|Self-pay|Self-pay|59||||59|20.65|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|59||||59|1.99|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59||||59|1.99|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59||||59|3.31|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|59||||59|2.37|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|59||||59|2.37|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59||||59|3.31|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59||||59|2.37|40.71|1.99
30585014|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMATOCRIT NON SPUN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59||||59|4.74|40.71|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AARP [1000]|AARP [100000]|58||||58|3.31|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58||||58|2.39|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AETNA [1015]|AETNA [101529]|58||||58|3.24|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58||||58|1.99|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58||||58|2.37|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58||||58|2.37|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BCBS UTHCT [115568]|58||||58|27.26|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58||||58|3.57|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58||||58|29|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58||||58|36.54|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58||||58|1.99|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58||||58|2.37|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|CIGNA [1260]|CIGNA GWH [126023]|58||||58|4.54|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|58||||58|40.02|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58||||58|2.96|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58||||58|2.37|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58||||58|3.24|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58||||58|1.99|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58||||58|2.37|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58||||58|3.24|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58||||58|1.99|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|58||||58|1.99|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|58||||58|40.02|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58||||58|1.99|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|Self-pay|Self-pay|58||||58|20.3|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58||||58|1.99|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58||||58|1.99|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58||||58|3.31|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58||||58|2.37|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58||||58|2.37|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58||||58|3.31|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58||||58|2.37|40.02|1.99
30585018|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEMOGLOBIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58||||58|4.74|40.02|1.99
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AARP [1000]|AARP [100000]|168||||168|10.86|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|168||||168|7.85|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AETNA [1015]|AETNA [101529]|168||||168|10.63|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|168||||168|6.53|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|168||||168|7.77|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|168||||168|7.77|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BCBS UTHCT [115568]|168||||168|78.96|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|168||||168|11.7|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|168||||168|84|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|168||||168|105.84|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|168||||168|6.53|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|168||||168|7.77|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|CIGNA [1260]|CIGNA GWH [126023]|168||||168|14.5|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|168||||168|115.92|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|168||||168|9.71|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|168||||168|7.77|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|168||||168|10.63|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|168||||168|6.53|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|168||||168|7.77|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|168||||168|10.63|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|168||||168|6.53|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|168||||168|6.53|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|168||||168|115.92|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|168||||168|6.53|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|Self-pay|Self-pay|168||||168|58.8|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|168||||168|6.53|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|168||||168|6.53|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|168||||168|10.86|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|168||||168|7.77|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|168||||168|7.77|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|168||||168|10.86|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|168||||168|7.77|115.92|6.53
30585025|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/AUTO DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|168||||168|15.54|115.92|6.53
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AARP [1000]|AARP [100000]|155||||155|9.04|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|155||||155|6.53|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AETNA [1015]|AETNA [101529]|155||||155|8.86|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|155||||155|5.43|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|155||||155|6.47|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|155||||155|6.47|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BCBS UTHCT [115568]|155||||155|72.85|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|155||||155|9.74|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|155||||155|77.5|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|155||||155|97.65|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|155||||155|5.43|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|155||||155|6.47|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|CIGNA [1260]|CIGNA GWH [126023]|155||||155|12.24|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|155||||155|106.95|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|155||||155|8.09|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|155||||155|6.47|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|155||||155|8.86|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|155||||155|5.43|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|155||||155|6.47|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|155||||155|8.86|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|155||||155|5.43|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|155||||155|5.43|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|155||||155|106.95|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|155||||155|5.43|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|Self-pay|Self-pay|155||||155|54.25|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|155||||155|5.43|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|155||||155|5.43|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|155||||155|9.04|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|155||||155|6.47|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|155||||155|6.47|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|155||||155|9.04|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|155||||155|6.47|106.95|5.43
30585027|EAP|0305 - LABORATORY-HEMATOLOGY|HC CBC AUTO W/O DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|155||||155|12.94|106.95|5.43
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AARP [1000]|AARP [100000]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AETNA [1015]|AETNA [101529]|65||||65|5.9|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS [1155]|BCBS UTHCT [115568]|65||||65|30.55|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65||||65|6.49|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65||||65|32.5|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65||||65|40.95|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|CIGNA [1260]|CIGNA GWH [126023]|65||||65|5.1|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|65||||65|44.85|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65||||65|5.39|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65||||65|5.9|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65||||65|5.9|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|65||||65|44.85|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|Self-pay|Self-pay|65||||65|22.75|44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65||||65||44.85|5.1
30585044|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65||||65||44.85|5.1
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AARP [1000]|AARP [100000]|76||||76|5.59|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76||||76|4.03|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AETNA [1015]|AETNA [101529]|76||||76|5.45|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76||||76|3.35|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76||||76|3.99|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76||||76|3.99|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BCBS UTHCT [115568]|76||||76|35.72|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76||||76|6.01|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76||||76|38|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76||||76|47.88|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76||||76|3.35|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76||||76|3.99|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|CIGNA [1260]|CIGNA GWH [126023]|76||||76|4.54|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|76||||76|52.44|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|76||||76|4.99|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76||||76|3.99|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76||||76|5.45|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76||||76|3.35|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76||||76|3.99|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76||||76|5.45|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76||||76|3.35|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|76||||76|3.35|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|76||||76|52.44|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76||||76|3.35|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|Self-pay|Self-pay|76||||76|26.6|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|76||||76|3.35|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76||||76|3.35|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76||||76|5.59|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|76||||76|3.99|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|76||||76|3.99|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76||||76|5.59|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76||||76|3.99|52.44|3.35
30585045|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT RETICULOCYTE AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76||||76|7.98|52.44|3.35
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|AARP [1000]|AARP [100000]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|AETNA [1015]|AETNA [101529]|48||||48|3.48|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|BCBS [1155]|BCBS UTHCT [115568]|48||||48|22.56|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48||||48|3.82|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48||||48|24|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48||||48|30.24|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|CIGNA [1260]|CIGNA GWH [126023]|48||||48|4.54|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|48||||48|33.12|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|48||||48|3.18|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48||||48|3.48|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48||||48|3.48|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|48||||48|33.12|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|Self-pay|Self-pay|48||||48|16.8|33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48||||48||33.12|3.18
30585048|EAP|0305 - LABORATORY-HEMATOLOGY|HC BLD CNT WBC AUTOMATED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48||||48||33.12|3.18
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AARP [1000]|AARP [100000]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AETNA [1015]|AETNA [101529]|94||||94|6.12|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS [1155]|BCBS UTHCT [115568]|94||||94|44.18|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|94||||94|6.75|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94||||94|47|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|94||||94|59.22|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|CIGNA [1260]|CIGNA GWH [126023]|94||||94|8.16|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|94||||94|64.86|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|94||||94|5.6|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94||||94|6.12|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94||||94|6.12|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|94||||94|64.86|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|Self-pay|Self-pay|94||||94|32.9|64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94||||94||64.86|5.6
30585049|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET CNT AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|94||||94||64.86|5.6
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AARP [1000]|AARP [100000]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AETNA [1015]|AETNA [101529]|347||||347|70.51|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|347||||347|102.89|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BCBS UTHCT [115568]|347||||347|163.09|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|347||||347|347|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|347||||347|173.5|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|347||||347|218.61|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|347||||347|102.89|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|CIGNA [1260]|CIGNA GWH [126023]|347||||347|54.05|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|347||||347|239.43|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|347||||347|820.19|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|347||||347|70.51|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|347||||347|102.89|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|347||||347|70.51|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|347||||347|102.89|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|347||||347|102.89|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|347||||347|239.43|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|347||||347|102.89|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|Self-pay|Self-pay|347||||347|121.45|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|347||||347|102.89|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|347||||347|102.89|820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|347||||347||820.19|54.05
30585097|EAP|0305 - LABORATORY-HEMATOLOGY|HC BONE MARROW INTERPRETATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|347||||347||820.19|54.05
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AARP [1000]|AARP [100000]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AETNA [1015]|AETNA [101529]|38||||38|17.76|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BCBS UTHCT [115568]|38||||38|17.86|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38||||38|19.56|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38||||38|19|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38||||38|23.94|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|CIGNA [1260]|CIGNA GWH [126023]|38||||38|15.02|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|38||||38|26.22|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|38||||38|16.23|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38||||38|17.76|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38||||38|17.76|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|38||||38|26.22|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|Self-pay|Self-pay|38||||38|13.3|26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38||||38||26.22|13.3
30585210|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38||||38||26.22|13.3
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AARP [1000]|AARP [100000]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AETNA [1015]|AETNA [101529]|65||||65|24.14|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BCBS UTHCT [115568]|65||||65|30.55|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65||||65|26.58|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65||||65|32.5|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65||||65|40.95|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|CIGNA [1260]|CIGNA GWH [126023]|65||||65|20.39|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|65||||65|44.85|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65||||65|22.06|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65||||65|24.14|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65||||65|24.14|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|65||||65|44.85|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|Self-pay|Self-pay|65||||65|22.75|44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65||||65||44.85|20.39
30585220|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR V LABILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65||||65||44.85|20.39
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AARP [1000]|AARP [100000]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AETNA [1015]|AETNA [101529]|153||||153|24.48|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BCBS UTHCT [115568]|153||||153|71.91|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|153||||153|26.96|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|153||||153|76.5|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|153||||153|96.39|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|CIGNA [1260]|CIGNA GWH [126023]|153||||153|20.68|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|GROUP PENSION ADMIN [1450]|GPA [145000]|153||||153|105.57|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|153||||153|22.38|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|153||||153|24.48|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|153||||153|24.48|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|PHCS [1780]|PHCS MULTIPLAN [178000]|153||||153|105.57|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|Self-pay|Self-pay|153||||153|53.55|105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|153||||153||105.57|20.68
30585230|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR VII|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|153||||153||105.57|20.68
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AARP [1000]|AARP [100000]|495||||495|25.02|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|495||||495|18.08|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AETNA [1015]|AETNA [101529]|495||||495|24.48|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|495||||495|15.04|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|495||||495|17.9|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|495||||495|17.9|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BCBS UTHCT [115568]|495||||495|232.65|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|495||||495|26.96|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|495||||495|247.5|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|495||||495|311.85|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|495||||495|15.04|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|495||||495|17.9|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|CIGNA [1260]|CIGNA GWH [126023]|495||||495|20.68|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|495||||495|341.55|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|495||||495|22.38|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|495||||495|17.9|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|495||||495|24.48|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|495||||495|15.04|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|495||||495|17.9|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|495||||495|24.48|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|495||||495|15.04|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|495||||495|15.04|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|495||||495|341.55|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|495||||495|15.04|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|Self-pay|Self-pay|495||||495|173.25|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|495||||495|15.04|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|495||||495|15.04|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|495||||495|25.02|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|495||||495|17.9|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|495||||495|17.9|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|495||||495|25.02|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|495||||495|17.9|341.55|15.04
30585240|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII AHG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|495||||495|35.8|341.55|15.04
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AARP [1000]|AARP [100000]|392||||392|32.06|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|392||||392|23.17|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AETNA [1015]|AETNA [101529]|392||||392|31.39|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|392||||392|19.27|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|392||||392|22.94|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|392||||392|22.94|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS [1155]|BCBS UTHCT [115568]|392||||392|184.24|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|392||||392|34.55|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|392||||392|196|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|392||||392|246.96|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|392||||392|19.27|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|392||||392|22.94|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|CIGNA [1260]|CIGNA GWH [126023]|392||||392|26.63|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|392||||392|270.48|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|392||||392|28.68|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|392||||392|22.94|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|392||||392|31.39|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|392||||392|19.27|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|392||||392|22.94|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|392||||392|31.39|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|392||||392|19.27|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|392||||392|19.27|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|392||||392|270.48|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|392||||392|19.27|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|Self-pay|Self-pay|392||||392|137.2|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|392||||392|19.27|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|392||||392|19.27|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|392||||392|32.06|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|392||||392|22.94|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|392||||392|22.94|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|392||||392|32.06|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|392||||392|22.94|270.48|19.27
30585245|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW RISTOCETIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|392||||392|45.88|270.48|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|AARP [1000]|AARP [100000]|309||||309|32.06|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|309||||309|23.17|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|AETNA [1015]|AETNA [101529]|309||||309|31.39|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|309||||309|19.27|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|309||||309|22.94|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|309||||309|22.94|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|BCBS [1155]|BCBS UTHCT [115568]|309||||309|145.23|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|309||||309|34.55|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|309||||309|154.5|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|309||||309|194.67|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|309||||309|19.27|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|309||||309|22.94|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|CIGNA [1260]|CIGNA GWH [126023]|309||||309|26.63|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|309||||309|213.21|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|309||||309|28.68|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|309||||309|22.94|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|309||||309|31.39|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|309||||309|19.27|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|309||||309|22.94|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|309||||309|31.39|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|309||||309|19.27|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|309||||309|19.27|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|309||||309|213.21|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|309||||309|19.27|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|Self-pay|Self-pay|309||||309|108.15|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|309||||309|19.27|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|309||||309|19.27|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|309||||309|32.06|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|309||||309|22.94|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|309||||309|22.94|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|309||||309|32.06|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|309||||309|22.94|213.21|19.27
30585246|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW AG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|309||||309|45.88|213.21|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|AARP [1000]|AARP [100000]|600||||600|32.06|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|600||||600|23.17|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|AETNA [1015]|AETNA [101529]|600||||600|31.39|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|600||||600|19.27|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|600||||600|22.94|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|600||||600|22.94|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|BCBS [1155]|BCBS UTHCT [115568]|600||||600|282|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|600||||600|34.55|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|600||||600|300|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|600||||600|378|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|600||||600|19.27|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|600||||600|22.94|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|CIGNA [1260]|CIGNA GWH [126023]|600||||600|26.63|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|600||||600|414|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|600||||600|28.68|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|600||||600|22.94|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|600||||600|31.39|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|600||||600|19.27|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|600||||600|22.94|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|600||||600|31.39|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|600||||600|19.27|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|600||||600|19.27|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|600||||600|414|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|600||||600|19.27|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|Self-pay|Self-pay|600||||600|210|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|600||||600|19.27|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|600||||600|19.27|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|600||||600|32.06|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|600||||600|22.94|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|600||||600|22.94|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|600||||600|32.06|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|600||||600|22.94|414|19.27
30585247|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR VIII VW MULTIMETRIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|600||||600|45.88|414|19.27
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AARP [1000]|AARP [100000]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AETNA [1015]|AETNA [101529]|471||||471|26.04|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS [1155]|BCBS UTHCT [115568]|471||||471|221.37|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|471||||471|28.68|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|471||||471|235.5|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|471||||471|296.73|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|CIGNA [1260]|CIGNA GWH [126023]|471||||471|22.09|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|471||||471|324.99|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|471||||471|23.8|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|471||||471|26.04|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|471||||471|26.04|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|471||||471|324.99|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|Self-pay|Self-pay|471||||471|164.85|324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|471||||471||324.99|22.09
30585250|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR IX CHRISTMAS/PTC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|471||||471||324.99|22.09
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AARP [1000]|AARP [100000]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AETNA [1015]|AETNA [101529]|76||||76|24.48|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BCBS UTHCT [115568]|76||||76|35.72|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76||||76|26.96|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76||||76|38|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76||||76|47.88|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|CIGNA [1260]|CIGNA GWH [126023]|76||||76|20.68|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|76||||76|52.44|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|76||||76|22.38|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76||||76|24.48|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76||||76|24.48|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|76||||76|52.44|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|Self-pay|Self-pay|76||||76|26.6|52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76||||76||52.44|20.68
30585260|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR X STUART-PROWER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76||||76||52.44|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AARP [1000]|AARP [100000]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AETNA [1015]|AETNA [101529]|192||||192|24.48|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BCBS UTHCT [115568]|192||||192|90.24|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|192||||192|26.96|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|192||||192|96|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|192||||192|120.96|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|CIGNA [1260]|CIGNA GWH [126023]|192||||192|20.68|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|192||||192|132.48|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|192||||192|22.38|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|192||||192|24.48|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|192||||192|24.48|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|192||||192|132.48|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|Self-pay|Self-pay|192||||192|67.2|132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|192||||192||132.48|20.68
30585270|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|192||||192||132.48|20.68
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|AARP [1000]|AARP [100000]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|AETNA [1015]|AETNA [101529]|54||||54|26.47|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|BCBS [1155]|BCBS UTHCT [115568]|54||||54|25.38|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54||||54|29.15|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54||||54|27|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54||||54|34.02|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|CIGNA [1260]|CIGNA GWH [126023]|54||||54|22.38|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54||||54|37.26|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54||||54|24.19|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54||||54|26.47|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54||||54|26.47|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54||||54|37.26|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|Self-pay|Self-pay|54||||54|18.9|37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54||||54||37.26|18.9
30585280|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR XII|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54||||54||37.26|18.9
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|AARP [1000]|AARP [100000]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|AETNA [1015]|AETNA [101529]|31||||31|12.46|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|13.4|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|CIGNA [1260]|CIGNA GWH [126023]|31||||31|10.2|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|11.39|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|12.46|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|12.46|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|Self-pay|Self-pay|31||||31|10.85|21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31||21.39|10.2
30585291|EAP|0305 - LABORATORY-HEMATOLOGY|HC CLOTTING FACTOR XIII FIBRN STABILIZ SCREEN SOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31||21.39|10.2
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AARP [1000]|AARP [100000]|229||||229|16.55|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|229||||229|11.97|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AETNA [1015]|AETNA [101529]|229||||229|16.2|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|229||||229|9.95|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|229||||229|11.85|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|229||||229|11.85|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS [1155]|BCBS UTHCT [115568]|229||||229|107.63|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|229||||229|17.85|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|229||||229|114.5|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|229||||229|144.27|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|229||||229|9.95|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|229||||229|11.85|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|CIGNA [1260]|CIGNA GWH [126023]|229||||229|13.88|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|229||||229|158.01|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|229||||229|14.81|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|229||||229|11.85|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|229||||229|16.2|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|229||||229|9.95|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|229||||229|11.85|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|229||||229|16.2|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|229||||229|9.95|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|229||||229|9.95|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|229||||229|158.01|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|229||||229|9.95|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|Self-pay|Self-pay|229||||229|80.15|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|229||||229|9.95|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|229||||229|9.95|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|229||||229|16.55|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|229||||229|11.85|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|229||||229|11.85|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|229||||229|16.55|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|229||||229|11.85|158.01|9.95
30585300|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|229||||229|23.7|158.01|9.95
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AARP [1000]|AARP [100000]|33||||33|15.11|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33||||33|10.92|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AETNA [1015]|AETNA [101529]|33||||33|14.78|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33||||33|9.08|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33||||33|10.81|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33||||33|10.81|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BCBS UTHCT [115568]|33||||33|15.51|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33||||33|16.29|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33||||33|16.5|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33||||33|20.79|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33||||33|9.08|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33||||33|10.81|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|CIGNA [1260]|CIGNA GWH [126023]|33||||33|12.47|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|33||||33|22.77|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33||||33|13.51|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33||||33|10.81|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33||||33|14.78|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33||||33|9.08|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33||||33|10.81|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33||||33|14.78|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33||||33|9.08|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|33||||33|9.08|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|33||||33|22.77|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33||||33|9.08|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|Self-pay|Self-pay|33||||33|11.55|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33||||33|9.08|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33||||33|9.08|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33||||33|15.11|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33||||33|10.81|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33||||33|10.81|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33||||33|15.11|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33||||33|10.81|22.77|9.08
30585301|EAP|0305 - LABORATORY-HEMATOLOGY|HC ANTITHROMBIN III ANTIGEN ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33||||33|21.62|22.77|9.08
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|AARP [1000]|AARP [100000]|478||||478|16.8|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|478||||478|12.13|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|AETNA [1015]|AETNA [101529]|478||||478|16.44|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|478||||478|10.09|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|478||||478|12.01|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|478||||478|12.01|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|BCBS [1155]|BCBS UTHCT [115568]|478||||478|224.66|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|478||||478|18.09|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|478||||478|239|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|478||||478|301.14|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|478||||478|10.09|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|478||||478|12.01|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|CIGNA [1260]|CIGNA GWH [126023]|478||||478|13.88|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|478||||478|329.82|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|478||||478|15.01|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|478||||478|12.01|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|478||||478|16.44|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|478||||478|10.09|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|478||||478|12.01|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|478||||478|16.44|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|478||||478|10.09|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|478||||478|10.09|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|478||||478|329.82|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|478||||478|10.09|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|Self-pay|Self-pay|478||||478|167.3|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|478||||478|10.09|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|478||||478|10.09|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|478||||478|16.8|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|478||||478|12.01|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|478||||478|12.01|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|478||||478|16.8|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|478||||478|12.01|329.82|10.09
30585302|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ANTIGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|478||||478|24.02|329.82|10.09
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AARP [1000]|AARP [100000]|404||||404|19.32|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|404||||404|13.98|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AETNA [1015]|AETNA [101529]|404||||404|18.94|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|404||||404|11.63|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|404||||404|13.84|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|404||||404|13.84|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BCBS UTHCT [115568]|404||||404|189.88|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|404||||404|20.84|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|404||||404|202|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|404||||404|254.52|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|404||||404|11.63|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|404||||404|13.84|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|CIGNA [1260]|CIGNA GWH [126023]|404||||404|16.14|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|404||||404|278.76|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|404||||404|17.3|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|404||||404|13.84|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|404||||404|18.94|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|404||||404|11.63|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|404||||404|13.84|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|404||||404|18.94|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|404||||404|11.63|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|404||||404|11.63|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|404||||404|278.76|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|404||||404|11.63|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|Self-pay|Self-pay|404||||404|141.4|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|404||||404|11.63|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|404||||404|11.63|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|404||||404|19.32|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|404||||404|13.84|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|404||||404|13.84|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|404||||404|19.32|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|404||||404|13.84|278.76|11.63
30585303|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN C ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|404||||404|27.68|278.76|11.63
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|AARP [1000]|AARP [100000]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|AETNA [1015]|AETNA [101529]|415||||415|20.95|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|BCBS [1155]|BCBS UTHCT [115568]|415||||415|195.05|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|415||||415|23.08|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|415||||415|207.5|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|415||||415|261.45|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|CIGNA [1260]|CIGNA GWH [126023]|415||||415|17.84|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|415||||415|286.35|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|415||||415|19.15|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|415||||415|20.95|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|415||||415|20.95|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|415||||415|286.35|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|Self-pay|Self-pay|415||||415|145.25|286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|415||||415||286.35|17.84
30585306|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTEIN S FREE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|415||||415||286.35|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AARP [1000]|AARP [100000]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AETNA [1015]|AETNA [101529]|426||||426|20.95|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS [1155]|BCBS UTHCT [115568]|426||||426|200.22|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|426||||426|23.08|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|426||||426|213|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|426||||426|268.38|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|CIGNA [1260]|CIGNA GWH [126023]|426||||426|17.84|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|426||||426|293.94|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|426||||426|19.15|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|426||||426|20.95|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|426||||426|20.95|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|426||||426|293.94|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|Self-pay|Self-pay|426||||426|149.1|293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|426||||426||293.94|17.84
30585307|EAP|0305 - LABORATORY-HEMATOLOGY|HC ACTIV PROTEIN C RESIST ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|426||||426||293.94|17.84
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AARP [1000]|AARP [100000]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AETNA [1015]|AETNA [101529]|298||||298|17.62|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BCBS UTHCT [115568]|298||||298|140.06|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|298||||298|19.39|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|298||||298|149|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|298||||298|187.74|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|CIGNA [1260]|CIGNA GWH [126023]|298||||298|15.02|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|298||||298|205.62|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|298||||298|16.09|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|298||||298|17.62|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|298||||298|17.62|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|298||||298|205.62|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|Self-pay|Self-pay|298||||298|104.3|205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|298||||298||205.62|15.02
30585335|EAP|0305 - LABORATORY-HEMATOLOGY|HC FACTOR INHIBITOR TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|298||||298||205.62|15.02
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AARP [1000]|AARP [100000]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AETNA [1015]|AETNA [101529]|190||||190|9.43|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BCBS UTHCT [115568]|190||||190|89.3|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|190||||190|10.38|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|190||||190|95|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|190||||190|119.7|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|CIGNA [1260]|CIGNA GWH [126023]|190||||190|7.93|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|190||||190|131.1|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|190||||190|8.61|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|190||||190|9.43|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|190||||190|9.43|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|190||||190|131.1|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|Self-pay|Self-pay|190||||190|66.5|131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|190||||190||131.1|7.93
30585362|EAP|0305 - LABORATORY-HEMATOLOGY|HC FDP/FSP AGGLUTINATION SQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|190||||190||131.1|7.93
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AARP [1000]|AARP [100000]|277||||277|9.97|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277||||277|9.82|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AETNA [1015]|AETNA [101529]|277||||277|13.3|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277||||277|8.16|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277||||277|9.72|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277||||277|9.72|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS [1155]|BCBS UTHCT [115568]|277||||277|130.19|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277||||277|11.86|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277||||277|138.5|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277||||277|174.51|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277||||277|8.16|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277||||277|9.72|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|CIGNA [1260]|CIGNA GWH [126023]|277||||277|8.21|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|277||||277|191.13|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|277||||277|12.15|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277||||277|9.72|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277||||277|13.3|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277||||277|8.16|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277||||277|9.72|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277||||277|13.3|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277||||277|8.16|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|277||||277|8.16|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|277||||277|191.13|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277||||277|8.16|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|Self-pay|Self-pay|277||||277|96.95|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|277||||277|8.16|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277||||277|8.16|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277||||277|9.97|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|277||||277|9.72|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|277||||277|9.72|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277||||277|9.97|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277||||277|9.72|191.13|8.16
30585378|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRIN DEGRADATION D-DIMER SQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277||||277|19.44|191.13|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AARP [1000]|AARP [100000]|144||||144|11.87|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|144||||144|9.82|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AETNA [1015]|AETNA [101529]|144||||144|13.3|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|144||||144|8.16|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|144||||144|9.72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|144||||144|9.72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BCBS UTHCT [115568]|144||||144|67.68|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|144||||144|12.8|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|144||||144|72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|144||||144|90.72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|144||||144|8.16|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|144||||144|9.72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|CIGNA [1260]|CIGNA GWH [126023]|144||||144|9.92|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|144||||144|99.36|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|144||||144|12.15|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|144||||144|9.72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|144||||144|13.3|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|144||||144|8.16|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|144||||144|9.72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|144||||144|13.3|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|144||||144|8.16|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|144||||144|8.16|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|144||||144|99.36|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|144||||144|8.16|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|Self-pay|Self-pay|144||||144|50.4|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|144||||144|8.16|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|144||||144|8.16|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|144||||144|11.87|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|144||||144|9.72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|144||||144|9.72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|144||||144|11.87|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|144||||144|9.72|99.36|8.16
30585384|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOGEN ACTIVITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|144||||144|19.44|99.36|8.16
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AARP [1000]|AARP [100000]|320||||320|33.51|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|320||||320|31.17|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AETNA [1015]|AETNA [101529]|320||||320|42.22|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|320||||320|25.92|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|320||||320|30.86|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|320||||320|30.86|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BCBS UTHCT [115568]|320||||320|150.4|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|320||||320|37.65|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|320||||320|160|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|320||||320|201.6|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|320||||320|25.92|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|320||||320|30.86|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|CIGNA [1260]|CIGNA GWH [126023]|320||||320|176|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|320||||320|220.8|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|320||||320|38.58|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|320||||320|30.86|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|320||||320|42.22|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|320||||320|25.92|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|320||||320|30.86|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|320||||320|42.22|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|320||||320|25.92|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|320||||320|25.92|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|320||||320|220.8|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|320||||320|25.92|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|Self-pay|Self-pay|320||||320|112|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|320||||320|25.92|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|320||||320|25.92|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|320||||320|33.51|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|320||||320|30.86|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|320||||320|30.86|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|320||||320|33.51|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|320||||320|30.86|220.8|25.92
30585397|EAP|0305 - LABORATORY-HEMATOLOGY|HC COAG FIBRIN EACH ANALYTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|320||||320|61.72|220.8|25.92
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|AARP [1000]|AARP [100000]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|AETNA [1015]|AETNA [101529]|106||||106|10.54|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|BCBS [1155]|BCBS UTHCT [115568]|106||||106|49.82|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|106||||106|11.6|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|106||||106|53|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|106||||106|66.78|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|CIGNA [1260]|CIGNA GWH [126023]|106||||106|9.07|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|106||||106|73.14|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|106||||106|9.64|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106||||106|10.54|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|106||||106|10.54|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|106||||106|73.14|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|Self-pay|Self-pay|106||||106|37.1|73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|106||||106||73.14|9.07
30585410|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC ALPHA-2 ANTI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|106||||106||73.14|9.07
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|AARP [1000]|AARP [100000]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|AETNA [1015]|AETNA [101529]|95||||95|23.52|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|BCBS [1155]|BCBS UTHCT [115568]|95||||95|44.65|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|95||||95|25.89|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|95||||95|47.5|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|95||||95|59.85|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|CIGNA [1260]|CIGNA GWH [126023]|95||||95|20.11|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|95||||95|65.55|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|95||||95|21.49|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95||||95|23.52|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95||||95|23.52|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|95||||95|65.55|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|Self-pay|Self-pay|95||||95|33.25|65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95||||95||65.55|20.11
30585415|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN ACTV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|95||||95||65.55|20.11
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|AARP [1000]|AARP [100000]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|AETNA [1015]|AETNA [101529]|27||||27|8.93|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|BCBS [1155]|BCBS UTHCT [115568]|27||||27|12.69|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27||||27|9.83|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27||||27|13.5|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27||||27|17.01|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|CIGNA [1260]|CIGNA GWH [126023]|27||||27|7.64|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|27||||27|18.63|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27||||27|8.16|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27||||27|8.93|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27||||27|8.93|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|27||||27|18.63|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|Self-pay|Self-pay|27||||27|9.45|18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27||||27||18.63|7.64
30585420|EAP|0305 - LABORATORY-HEMATOLOGY|HC FIBRINOLYTIC PLASMINOGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27||||27||18.63|7.64
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AARP [1000]|AARP [100000]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AETNA [1015]|AETNA [101529]|99||||99|17.9|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BCBS UTHCT [115568]|99||||99|46.53|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99||||99|19.72|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99||||99|49.5|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99||||99|62.37|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|CIGNA [1260]|CIGNA GWH [126023]|99||||99|15.29|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|99||||99|68.31|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|99||||99|16.36|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99||||99|17.9|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99||||99|17.9|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|99||||99|68.31|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|Self-pay|Self-pay|99||||99|34.65|68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99||||99||68.31|15.29
30585520|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN ASSAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99||||99||68.31|15.29
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|AARP [1000]|AARP [100000]|89||||89|16.55|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89||||89|11.96|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|AETNA [1015]|AETNA [101529]|89||||89|16.2|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89||||89|9.95|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89||||89|11.84|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|89||||89|11.84|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|BCBS [1155]|BCBS UTHCT [115568]|89||||89|41.83|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89||||89|17.84|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89||||89|44.5|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89||||89|56.07|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89||||89|9.95|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89||||89|11.84|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|CIGNA [1260]|CIGNA GWH [126023]|89||||89|13.88|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|89||||89|61.41|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|89||||89|14.8|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|89||||89|11.84|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89||||89|16.2|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89||||89|9.95|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89||||89|11.84|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89||||89|16.2|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|89||||89|9.95|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|89||||89|9.95|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|89||||89|61.41|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89||||89|9.95|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|Self-pay|Self-pay|89||||89|31.15|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|89||||89|9.95|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89||||89|9.95|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89||||89|16.55|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|89||||89|11.84|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|89||||89|11.84|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89||||89|16.55|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89||||89|11.84|61.41|9.95
30585525|EAP|0305 - LABORATORY-HEMATOLOGY|HC HEPARIN NEUTRALIZATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|89||||89|23.68|61.41|9.95
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|AARP [1000]|AARP [100000]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|AETNA [1015]|AETNA [101529]|66||||66|11.76|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|BCBS [1155]|BCBS UTHCT [115568]|66||||66|31.02|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|12.96|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|41.58|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|CIGNA [1260]|CIGNA GWH [126023]|66||||66|9.92|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66||||66|10.75|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|11.76|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|11.76|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|Self-pay|Self-pay|66||||66|23.1|45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||45.54|9.92
30585540|EAP|0305 - LABORATORY-HEMATOLOGY|HC LEUKO ALKALINE PHOSPHATASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||45.54|9.92
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|AARP [1000]|AARP [100000]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|AETNA [1015]|AETNA [101529]|151||||151|25.66|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|BCBS [1155]|BCBS UTHCT [115568]|151||||151|70.97|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|151||||151|28.24|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|151||||151|75.5|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|151||||151|95.13|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|CIGNA [1260]|CIGNA GWH [126023]|151||||151|21.82|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|151||||151|104.19|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|151||||151|23.44|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|151||||151|25.66|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|151||||151|25.66|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|151||||151|104.19|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|Self-pay|Self-pay|151||||151|52.85|104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|151||||151||104.19|21.82
30585549|EAP|0305 - LABORATORY-HEMATOLOGY|HC MURAMIDASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|151||||151||104.19|21.82
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|AARP [1000]|AARP [100000]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|AETNA [1015]|AETNA [101529]|83||||83|10.22|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|BCBS [1155]|BCBS UTHCT [115568]|83||||83|39.01|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83||||83|10.07|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83||||83|41.5|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83||||83|52.29|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|CIGNA [1260]|CIGNA GWH [126023]|83||||83|7.64|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|83||||83|57.27|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|83||||83|9.34|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83||||83|10.22|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83||||83|10.22|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|83||||83|57.27|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|Self-pay|Self-pay|83||||83|29.05|57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83||||83||57.27|7.64
30585555|EAP|0305 - LABORATORY-HEMATOLOGY|HC OSMOTIC FRAGILITY RBC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83||||83||57.27|7.64
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AARP [1000]|AARP [100000]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AETNA [1015]|AETNA [101529]|183||||183|34.08|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BCBS UTHCT [115568]|183||||183|86.01|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|183||||183|32.35|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|183||||183|91.5|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|183||||183|115.29|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|CIGNA [1260]|CIGNA GWH [126023]|183||||183|38.32|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|183||||183|126.27|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|183||||183|31.14|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|183||||183|34.08|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|183||||183|34.08|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|183||||183|126.27|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|Self-pay|Self-pay|183||||183|64.05|126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|183||||183||126.27|31.14
30585576|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET AGGREGATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|183||||183||126.27|31.14
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|AARP [1000]|AARP [100000]|86||||86|25.12|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|86||||86|18.16|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|AETNA [1015]|AETNA [101529]|86||||86|24.6|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|86||||86|15.1|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|86||||86|17.98|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|86||||86|17.98|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|BCBS [1155]|BCBS UTHCT [115568]|86||||86|40.42|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|86||||86|27.07|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|86||||86|43|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|86||||86|54.18|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|86||||86|15.1|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|86||||86|17.98|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|CIGNA [1260]|CIGNA GWH [126023]|86||||86|20.96|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|86||||86|59.34|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|86||||86|22.48|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|86||||86|17.98|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86||||86|24.6|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|86||||86|15.1|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|86||||86|17.98|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|86||||86|24.6|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|86||||86|15.1|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|86||||86|15.1|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|86||||86|59.34|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|86||||86|15.1|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|Self-pay|Self-pay|86||||86|30.1|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|86||||86|15.1|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|86||||86|15.1|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|86||||86|25.12|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|86||||86|17.98|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|86||||86|17.98|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|86||||86|25.12|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|86||||86|17.98|59.34|15.1
30585597|EAP|0305 - LABORATORY-HEMATOLOGY|HC PLATELET NEUTRALIZATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|86||||86|35.96|59.34|15.1
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AARP [1000]|AARP [100000]|122||||122|5.49|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122||||122|4.33|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AETNA [1015]|AETNA [101529]|122||||122|5.88|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122||||122|3.6|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122||||122|4.29|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122||||122|4.29|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BCBS UTHCT [115568]|122||||122|57.34|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122||||122|5.92|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122||||122|61|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122||||122|76.86|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122||||122|3.6|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122||||122|4.29|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|CIGNA [1260]|CIGNA GWH [126023]|122||||122|7.26|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|122||||122|84.18|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|122||||122|5.36|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122||||122|4.29|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122||||122|5.88|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122||||122|3.6|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122||||122|4.29|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122||||122|5.88|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122||||122|3.6|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|122||||122|3.6|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|122||||122|84.18|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122||||122|3.6|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|Self-pay|Self-pay|122||||122|42.7|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|122||||122|3.6|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122||||122|3.6|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122||||122|5.49|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|122||||122|4.29|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|122||||122|4.29|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122||||122|5.49|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122||||122|4.29|84.18|3.6
30585610|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME (PT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122||||122|8.58|84.18|3.6
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|AARP [1000]|AARP [100000]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|AETNA [1015]|AETNA [101529]|14||||14|5.4|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|BCBS [1155]|BCBS UTHCT [115568]|14||||14|6.58|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14||||14|5.94|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14||||14|7|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14||||14|8.82|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|CIGNA [1260]|CIGNA GWH [126023]|14||||14|4.54|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|14||||14|9.66|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14||||14|4.93|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14||||14|5.4|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14||||14|5.4|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|14||||14|9.66|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|Self-pay|Self-pay|14||||14|4.9|9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14||||14||9.66|4.54
30585611|EAP|0305 - LABORATORY-HEMATOLOGY|HC PROTHROMBIN TIME SUBSTITUTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14||||14||9.66|4.54
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AARP [1000]|AARP [100000]|50||||50|13.37|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50||||50|9.68|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AETNA [1015]|AETNA [101529]|50||||50|13.1|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50||||50|8.05|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50||||50|9.58|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50||||50|9.58|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BCBS UTHCT [115568]|50||||50|23.5|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50||||50|14.43|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50||||50|25|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50||||50|31.5|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50||||50|8.05|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50||||50|9.58|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|CIGNA [1260]|CIGNA GWH [126023]|50||||50|11.04|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|50||||50|34.5|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50||||50|11.98|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50||||50|9.58|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50||||50|13.1|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50||||50|8.05|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50||||50|9.58|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50||||50|13.1|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50||||50|8.05|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|50||||50|8.05|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|50||||50|34.5|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50||||50|8.05|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|Self-pay|Self-pay|50||||50|17.5|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50||||50|8.05|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50||||50|8.05|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50||||50|13.37|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50||||50|9.58|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50||||50|9.58|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50||||50|13.37|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50||||50|9.58|34.5|8.05
30585613|EAP|0305 - LABORATORY-HEMATOLOGY|HC RUSSELL VIPER VENOM DILUTED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50||||50|19.16|34.5|8.05
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|AARP [1000]|AARP [100000]|54||||54|13.76|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54||||54|9.95|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|AETNA [1015]|AETNA [101529]|54||||54|13.46|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54||||54|8.27|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54||||54|9.85|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54||||54|9.85|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|BCBS [1155]|BCBS UTHCT [115568]|54||||54|25.38|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54||||54|14.84|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54||||54|27|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54||||54|34.02|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54||||54|8.27|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54||||54|9.85|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|CIGNA [1260]|CIGNA GWH [126023]|54||||54|11.33|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54||||54|37.26|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54||||54|12.31|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54||||54|9.85|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54||||54|13.46|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54||||54|8.27|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54||||54|9.85|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54||||54|13.46|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54||||54|8.27|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54||||54|8.27|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54||||54|37.26|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54||||54|8.27|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|Self-pay|Self-pay|54||||54|18.9|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54||||54|8.27|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54||||54|8.27|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54||||54|13.76|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54||||54|9.85|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54||||54|9.85|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54||||54|13.76|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54||||54|9.85|37.26|8.27
30585635|EAP|0305 - LABORATORY-HEMATOLOGY|HC REPTILASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54||||54|19.7|37.26|8.27
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|AARP [1000]|AARP [100000]|94||||94|4.96|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94||||94|4.31|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|AETNA [1015]|AETNA [101529]|94||||94|5.83|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94||||94|3.59|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94||||94|4.27|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|94||||94|4.27|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|BCBS [1155]|BCBS UTHCT [115568]|94||||94|44.18|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|94||||94|5.34|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94||||94|47|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|94||||94|59.22|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|94||||94|3.59|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94||||94|4.27|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|CIGNA [1260]|CIGNA GWH [126023]|94||||94|4.25|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|94||||94|64.86|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|94||||94|5.34|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|94||||94|4.27|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94||||94|5.83|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94||||94|3.59|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94||||94|4.27|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94||||94|5.83|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|94||||94|3.59|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|94||||94|3.59|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|94||||94|64.86|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94||||94|3.59|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|Self-pay|Self-pay|94||||94|32.9|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|94||||94|3.59|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|94||||94|3.59|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94||||94|4.96|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|94||||94|4.27|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|94||||94|4.27|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94||||94|4.96|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94||||94|4.27|64.86|3.59
30585651|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC NON AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|94||||94|8.54|64.86|3.59
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AARP [1000]|AARP [100000]|75||||75|3.77|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75||||75|2.73|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AETNA [1015]|AETNA [101529]|75||||75|3.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75||||75|2.27|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75||||75|2.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75||||75|2.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BCBS UTHCT [115568]|75||||75|35.25|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75||||75|4.06|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75||||75|37.5|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75||||75|47.25|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75||||75|2.27|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75||||75|2.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|CIGNA [1260]|CIGNA GWH [126023]|75||||75|3.11|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|75||||75|51.75|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|75||||75|3.38|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75||||75|2.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75||||75|3.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75||||75|2.27|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75||||75|2.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75||||75|3.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75||||75|2.27|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|75||||75|2.27|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|75||||75|51.75|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75||||75|2.27|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|Self-pay|Self-pay|75||||75|26.25|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|75||||75|2.27|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75||||75|2.27|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75||||75|3.77|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|75||||75|2.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|75||||75|2.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75||||75|3.77|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75||||75|2.7|51.75|2.27
30585652|EAP|0305 - LABORATORY-HEMATOLOGY|HC SED RATE RBC AUTO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75||||75|5.4|51.75|2.27
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|AARP [1000]|AARP [100000]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|AETNA [1015]|AETNA [101529]|84||||84|7.54|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|BCBS [1155]|BCBS UTHCT [115568]|84||||84|39.48|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|84||||84|8.3|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|84||||84|42|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|84||||84|52.92|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|CIGNA [1260]|CIGNA GWH [126023]|84||||84|6.5|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|84||||84|57.96|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|84||||84|6.89|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|84||||84|7.54|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|84||||84|7.54|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|84||||84|57.96|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|Self-pay|Self-pay|84||||84|29.4|57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|84||||84||57.96|6.5
30585660|EAP|0305 - LABORATORY-HEMATOLOGY|HC SICKLING RBC REDUCTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|84||||84||57.96|6.5
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|AARP [1000]|AARP [100000]|20||||20|8.07|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20|5.83|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|AETNA [1015]|AETNA [101529]|20||||20|7.9|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20|4.85|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20|5.77|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20||||20|5.77|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|BCBS [1155]|BCBS UTHCT [115568]|20||||20|9.4|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|8.69|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|10|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|12.6|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20|4.85|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20|5.77|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|CIGNA [1260]|CIGNA GWH [126023]|20||||20|6.79|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20||||20|7.21|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20||||20|5.77|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|7.9|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20|4.85|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20|5.77|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|7.9|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20||||20|4.85|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20||||20|4.85|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20|4.85|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|Self-pay|Self-pay|20||||20|7|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20||||20|4.85|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20|4.85|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20|8.07|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20||||20|5.77|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20||||20|5.77|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20|8.07|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20|5.77|13.8|4.85
30585670|EAP|0305 - LABORATORY-HEMATOLOGY|HC THROMBIN TIME PLASMA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20||||20|11.54|13.8|4.85
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AARP [1000]|AARP [100000]|138||||138|8.38|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138||||138|6.07|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AETNA [1015]|AETNA [101529]|138||||138|8.23|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138||||138|5.05|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138||||138|6.01|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138||||138|6.01|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BCBS UTHCT [115568]|138||||138|64.86|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138||||138|9.05|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138||||138|69|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138||||138|86.94|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138||||138|5.05|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138||||138|6.01|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|CIGNA [1260]|CIGNA GWH [126023]|138||||138|7.08|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|138||||138|95.22|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138||||138|7.51|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138||||138|6.01|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138||||138|8.23|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138||||138|5.05|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138||||138|6.01|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138||||138|8.23|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138||||138|5.05|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|138||||138|5.05|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|138||||138|95.22|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138||||138|5.05|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|Self-pay|Self-pay|138||||138|48.3|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138||||138|5.05|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138||||138|5.05|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138||||138|8.38|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138||||138|6.01|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138||||138|6.01|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138||||138|8.38|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138||||138|6.01|95.22|5.05
30585730|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138||||138|12.02|95.22|5.05
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|AARP [1000]|AARP [100000]|307||||307|9.04|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|307||||307|6.53|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|AETNA [1015]|AETNA [101529]|307||||307|8.86|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|307||||307|5.43|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|307||||307|6.47|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|307||||307|6.47|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|BCBS [1155]|BCBS UTHCT [115568]|307||||307|144.29|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|307||||307|9.74|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|307||||307|153.5|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|307||||307|193.41|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|307||||307|5.43|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|307||||307|6.47|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|CIGNA [1260]|CIGNA GWH [126023]|307||||307|7.64|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|307||||307|211.83|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|307||||307|8.09|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|307||||307|6.47|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|307||||307|8.86|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|307||||307|5.43|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|307||||307|6.47|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|307||||307|8.86|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|307||||307|5.43|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|307||||307|5.43|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|307||||307|211.83|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|307||||307|5.43|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|Self-pay|Self-pay|307||||307|107.45|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|307||||307|5.43|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|307||||307|5.43|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|307||||307|9.04|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|307||||307|6.47|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|307||||307|6.47|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|307||||307|9.04|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|307||||307|6.47|211.83|5.43
30585732|EAP|0305 - LABORATORY-HEMATOLOGY|HC PTT SUBSTITUTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|307||||307|12.94|211.83|5.43
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|AARP [1000]|AARP [100000]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|AETNA [1015]|AETNA [101529]|55||||55|15.96|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|BCBS [1155]|BCBS UTHCT [115568]|55||||55|25.85|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|55||||55|17.58|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|55||||55|27.5|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|55||||55|34.65|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|CIGNA [1260]|CIGNA GWH [126023]|55||||55|13.6|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|55||||55|37.95|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|55||||55|14.59|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55||||55|15.96|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55||||55|15.96|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|55||||55|37.95|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|Self-pay|Self-pay|55||||55|19.25|37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|55||||55||37.95|13.6
30585810|EAP|0305 - LABORATORY-HEMATOLOGY|HC VISCOSITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|55||||55||37.95|13.6
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|AARP [1000]|AARP [100000]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|AETNA [1015]|AETNA [101529]|168||||168|72.53|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|168||||168|49.81|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|BCBS [1155]|BCBS UTHCT [115568]|168||||168|78.96|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|168||||168|157.6|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|168||||168|84|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|168||||168|105.84|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|168||||168|49.81|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|CIGNA [1260]|CIGNA GWH [126023]|168||||168|33.77|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|168||||168|115.92|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|168||||168|186.45|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|168||||168|72.53|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|168||||168|49.81|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|168||||168|72.53|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|168||||168|49.81|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|168||||168|49.81|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|168||||168|115.92|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|168||||168|49.81|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|Self-pay|Self-pay|168||||168|58.8|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|168||||168|49.81|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|168||||168|49.81|186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|168||||168||186.45|33.77
30586078|EAP|0305 - LABORATORY-HEMATOLOGY|HC TRANSFUSION REACTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|168||||168||186.45|33.77
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AARP [1000]|AARP [100000]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AETNA [1015]|AETNA [101529]|140||||140|61.74|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS [1155]|BCBS UTHCT [115568]|140||||140|65.8|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|140||||140|62.6|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|140||||140|70|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|140||||140|88.2|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|CIGNA [1260]|CIGNA GWH [126023]|140||||140|77|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|140||||140|96.6|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|140||||140|66.72|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|140||||140|61.74|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|140||||140|61.74|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|140||||140|96.6|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|Self-pay|Self-pay|140||||140|49|96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|140||||140||96.6|49
30600002|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CORONAVIRUS SARS-COV-2/2019-NCOV (COVID-19)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|140||||140||96.6|49
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|AARP [1000]|AARP [100000]|200||||200|100|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|200||||200|75.75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|AETNA [1015]|AETNA [101529]|200||||200|88.2|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|BCBS [1155]|BCBS UTHCT [115568]|200||||200|94|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|200||||200|122|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|200||||200|100|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|200||||200|126|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|CIGNA [1260]|CIGNA GWH [126023]|200||||200|110|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|200||||200|138|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|200||||200|130|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|200||||200|88.2|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|200||||200|88.2|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|200||||200|138|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|Self-pay|Self-pay|200||||200|70|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|200||||200|100|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|200||||200|100|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|200||||200|75|150|70
30600003|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DNA/RNA SARS-COV-2/COVID-19 AMP HIGH THROUGHPUT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|200||||200|150|150|70
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|AARP [1000]|AARP [100000]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|AETNA [1015]|AETNA [101529]|428||||428|188.75|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|428||||428|126.9|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|BCBS [1155]|BCBS UTHCT [115568]|428||||428|201.16|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|428||||428|174.01|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|428||||428|214|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|428||||428|269.64|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|428||||428|126.9|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|CIGNA [1260]|CIGNA GWH [126023]|428||||428|235.4|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|GROUP PENSION ADMIN [1450]|GPA [145000]|428||||428|295.32|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|428||||428|214|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|428||||428|188.75|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|428||||428|126.9|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|428||||428|188.75|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|428||||428|126.9|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|428||||428|126.9|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|PHCS [1780]|PHCS MULTIPLAN [178000]|428||||428|295.32|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|428||||428|126.9|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|Self-pay|Self-pay|428||||428|149.8|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|428||||428|126.9|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|428||||428|126.9|295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|428||||428||295.32|126.9
30602410|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RNA 4 TARGETS SARS-COV-2 RSV FLU A B|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|428||||428||295.32|126.9
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|AARP [1000]|AARP [100000]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.15||||0.15|0.07|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.15||||0.15|0.04|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.15||||0.15|0.07|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.15||||0.15|0.08|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.15||||0.15|0.08|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.15||||0.15|0.09|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.15||||0.15|0.04|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.15||||0.15|0.08|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.15||||0.15|0.1|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.15||||0.15|0.08|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.15||||0.15|0.07|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.15||||0.15|0.04|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.15||||0.15|0.07|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.15||||0.15|0.04|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.15||||0.15|0.04|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.15||||0.15|0.1|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.15||||0.15|0.04|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|Self-pay|Self-pay|0.15||||0.15|0.05|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.15||||0.15|0.04|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.15||||0.15|0.04|0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.15||||0.15||0.1|0.04
3066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS GLUCONATE 324 MG (38 MG IRON) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.15||||0.15||0.1|0.04
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AARP [1000]|AARP [100000]|67||||67|9.33|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|67||||67|6.75|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AETNA [1015]|AETNA [101529]|67||||67|9.14|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|67||||67|5.61|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|67||||67|6.68|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|67||||67|6.68|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS [1155]|BCBS UTHCT [115568]|67||||67|31.49|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|67||||67|10.05|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|67||||67|33.5|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|67||||67|42.21|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|67||||67|5.61|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|67||||67|6.68|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|CIGNA [1260]|CIGNA GWH [126023]|67||||67|7.64|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|67||||67|46.23|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|67||||67|8.35|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|67||||67|6.68|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|67||||67|9.14|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|67||||67|5.61|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|67||||67|6.68|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|67||||67|9.14|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|67||||67|5.61|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|67||||67|5.61|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|67||||67|46.23|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|67||||67|5.61|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|Self-pay|Self-pay|67||||67|23.45|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|67||||67|5.61|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|67||||67|5.61|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|67||||67|9.33|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|67||||67|6.68|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|67||||67|6.68|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|67||||67|9.33|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|67||||67|6.68|46.23|5.61
30687015|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CONCENTRATION INFECTIOUS AGNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|67||||67|13.36|46.23|5.61
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AARP [1000]|AARP [100000]|196||||196|14.42|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|196||||196|10.42|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AETNA [1015]|AETNA [101529]|196||||196|14.11|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|196||||196|8.67|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|196||||196|10.32|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|196||||196|10.32|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BCBS UTHCT [115568]|196||||196|92.12|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|196||||196|15.54|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|196||||196|98|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|196||||196|123.48|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|196||||196|8.67|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|196||||196|10.32|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|CIGNA [1260]|CIGNA GWH [126023]|196||||196|11.89|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|196||||196|135.24|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|196||||196|12.9|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|196||||196|10.32|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|196||||196|14.11|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|196||||196|8.67|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|196||||196|10.32|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|196||||196|14.11|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|196||||196|8.67|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|196||||196|8.67|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|196||||196|135.24|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|196||||196|8.67|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|Self-pay|Self-pay|196||||196|68.6|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|196||||196|8.67|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|196||||196|8.67|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|196||||196|14.42|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|196||||196|10.32|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|196||||196|10.32|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|196||||196|14.42|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|196||||196|10.32|135.24|8.67
30687040|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|196||||196|20.64|135.24|8.67
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AARP [1000]|AARP [100000]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AETNA [1015]|AETNA [101529]|139||||139|12.91|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BCBS UTHCT [115568]|139||||139|65.33|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139||||139|14.23|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139||||139|69.5|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139||||139|87.57|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|CIGNA [1260]|CIGNA GWH [126023]|139||||139|11.04|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|139||||139|95.91|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|139||||139|11.8|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139||||139|12.91|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139||||139|12.91|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|139||||139|95.91|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|Self-pay|Self-pay|139||||139|48.65|95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139||||139||95.91|11.04
30687045|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139||||139||95.91|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AARP [1000]|AARP [100000]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AETNA [1015]|AETNA [101529]|68||||68|12.91|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS [1155]|BCBS UTHCT [115568]|68||||68|31.96|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|68||||68|14.23|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|68||||68|34|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|68||||68|42.84|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|CIGNA [1260]|CIGNA GWH [126023]|68||||68|11.04|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|68||||68|46.92|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|68||||68|11.8|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|68||||68|12.91|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|68||||68|12.91|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|68||||68|46.92|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|Self-pay|Self-pay|68||||68|23.8|46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|68||||68||46.92|11.04
30687046|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE STOOL/ADD PATHOGENS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|68||||68||46.92|11.04
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AARP [1000]|AARP [100000]|154||||154|12.03|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|154||||154|8.71|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AETNA [1015]|AETNA [101529]|154||||154|11.78|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|154||||154|7.24|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|154||||154|8.62|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|154||||154|8.62|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BCBS UTHCT [115568]|154||||154|72.38|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|154||||154|12.98|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|154||||154|77|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|154||||154|97.02|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|154||||154|7.24|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|154||||154|8.62|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|CIGNA [1260]|CIGNA GWH [126023]|154||||154|9.92|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|154||||154|106.26|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|154||||154|10.78|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|154||||154|8.62|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|154||||154|11.78|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|154||||154|7.24|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|154||||154|8.62|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|154||||154|11.78|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|154||||154|7.24|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|154||||154|7.24|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|154||||154|106.26|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|154||||154|7.24|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|Self-pay|Self-pay|154||||154|53.9|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|154||||154|7.24|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|154||||154|7.24|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|154||||154|12.03|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|154||||154|8.62|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|154||||154|8.62|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|154||||154|12.03|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|154||||154|8.62|106.26|7.24
30687070|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANY OTHER SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|154||||154|17.24|106.26|7.24
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AARP [1000]|AARP [100000]|214||||214|13.22|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214|9.56|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AETNA [1015]|AETNA [101529]|214||||214|12.96|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|7.95|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214|9.47|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214|9.47|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BCBS UTHCT [115568]|214||||214|100.58|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|14.26|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|107|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|134.82|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|7.95|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214|9.47|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|CIGNA [1260]|CIGNA GWH [126023]|214||||214|11.04|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214||||214|11.84|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214|9.47|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|12.96|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|7.95|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214|9.47|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|12.96|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|7.95|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214||||214|7.95|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|7.95|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|Self-pay|Self-pay|214||||214|74.9|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214||||214|7.95|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|7.95|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214|13.22|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214||||214|9.47|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214||||214|9.47|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214|13.22|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214|9.47|147.66|7.95
30687075|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ANY SOURCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214|18.94|147.66|7.95
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AARP [1000]|AARP [100000]|136||||136|11.29|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136||||136|8.16|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AETNA [1015]|AETNA [101529]|136||||136|11.06|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136||||136|6.79|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136||||136|8.08|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136||||136|8.08|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BCBS UTHCT [115568]|136||||136|63.92|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136||||136|12.16|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136||||136|68|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136||||136|85.68|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136||||136|6.79|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136||||136|8.08|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|CIGNA [1260]|CIGNA GWH [126023]|136||||136|9.35|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|136||||136|93.84|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|136||||136|10.1|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136||||136|8.08|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136||||136|11.06|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136||||136|6.79|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136||||136|8.08|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136||||136|11.06|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136||||136|6.79|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|136||||136|6.79|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|136||||136|93.84|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136||||136|6.79|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|Self-pay|Self-pay|136||||136|47.6|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|136||||136|6.79|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136||||136|6.79|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136||||136|11.29|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|136||||136|8.08|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|136||||136|8.08|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136||||136|11.29|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136||||136|8.08|93.84|6.79
30687076|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE ANAEROBIC ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136||||136|16.16|93.84|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AARP [1000]|AARP [100000]|144||||144|11.29|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|144||||144|8.16|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AETNA [1015]|AETNA [101529]|144||||144|11.06|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|144||||144|6.79|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|144||||144|8.08|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|144||||144|8.08|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BCBS UTHCT [115568]|144||||144|67.68|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|144||||144|12.16|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|144||||144|72|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|144||||144|90.72|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|144||||144|6.79|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|144||||144|8.08|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|CIGNA [1260]|CIGNA GWH [126023]|144||||144|9.35|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|144||||144|99.36|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|144||||144|10.1|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|144||||144|8.08|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|144||||144|11.06|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|144||||144|6.79|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|144||||144|8.08|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|144||||144|11.06|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|144||||144|6.79|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|144||||144|6.79|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|144||||144|99.36|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|144||||144|6.79|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|Self-pay|Self-pay|144||||144|50.4|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|144||||144|6.79|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|144||||144|6.79|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|144||||144|11.29|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|144||||144|8.08|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|144||||144|8.08|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|144||||144|11.29|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|144||||144|8.08|99.36|6.79
30687077|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AER ORGANISM ID EA ISOLATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|144||||144|16.16|99.36|6.79
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AARP [1000]|AARP [100000]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AETNA [1015]|AETNA [101529]|110||||110|9.07|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BCBS UTHCT [115568]|110||||110|51.7|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|110||||110|9.98|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|110||||110|55|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|110||||110|69.3|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|CIGNA [1260]|CIGNA GWH [126023]|110||||110|12.24|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|110||||110|75.9|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|110||||110|8.29|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|110||||110|9.07|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|110||||110|9.07|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|110||||110|75.9|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|Self-pay|Self-pay|110||||110|38.5|75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|110||||110||75.9|8.29
30687081|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PATHOGENIC IS ORG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|110||||110||75.9|8.29
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AARP [1000]|AARP [100000]|136||||136|11.28|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136||||136|8.15|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AETNA [1015]|AETNA [101529]|136||||136|11.04|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136||||136|6.78|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136||||136|8.07|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136||||136|8.07|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BCBS UTHCT [115568]|136||||136|63.92|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136||||136|12.15|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136||||136|68|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136||||136|85.68|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136||||136|6.78|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136||||136|8.07|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|CIGNA [1260]|CIGNA GWH [126023]|136||||136|9.35|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|136||||136|93.84|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|136||||136|10.09|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136||||136|8.07|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136||||136|11.04|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136||||136|6.78|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136||||136|8.07|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136||||136|11.04|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136||||136|6.78|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|136||||136|6.78|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|136||||136|93.84|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136||||136|6.78|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|Self-pay|Self-pay|136||||136|47.6|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|136||||136|6.78|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136||||136|6.78|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136||||136|11.28|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|136||||136|8.07|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|136||||136|8.07|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136||||136|11.28|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136||||136|8.07|93.84|6.78
30687086|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE URINE W/COLONY CNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136||||136|16.14|93.84|6.78
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AARP [1000]|AARP [100000]|139||||139|10.77|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|139||||139|7.79|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AETNA [1015]|AETNA [101529]|139||||139|10.54|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|139||||139|6.48|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|139||||139|7.71|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|139||||139|7.71|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BCBS UTHCT [115568]|139||||139|65.33|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|139||||139|11.6|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|139||||139|69.5|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|139||||139|87.57|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|139||||139|6.48|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|139||||139|7.71|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|CIGNA [1260]|CIGNA GWH [126023]|139||||139|9.07|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|139||||139|95.91|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|139||||139|9.64|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|139||||139|7.71|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|139||||139|10.54|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|139||||139|6.48|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|139||||139|7.71|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|139||||139|10.54|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|139||||139|6.48|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|139||||139|6.48|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|139||||139|95.91|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|139||||139|6.48|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|Self-pay|Self-pay|139||||139|48.65|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|139||||139|6.48|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|139||||139|6.48|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|139||||139|10.77|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|139||||139|7.71|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|139||||139|7.71|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|139||||139|10.77|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|139||||139|7.71|95.91|6.48
30687101|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT FUNGI ID ISOLATES SKIN/HAIR/NAIL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|139||||139|15.42|95.91|6.48
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AARP [1000]|AARP [100000]|158||||158|11.74|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158||||158|8.49|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AETNA [1015]|AETNA [101529]|158||||158|11.5|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158||||158|7.06|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158||||158|8.41|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158||||158|8.41|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BCBS UTHCT [115568]|158||||158|74.26|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158||||158|12.66|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158||||158|79|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158||||158|99.54|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158||||158|7.06|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158||||158|8.41|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|CIGNA [1260]|CIGNA GWH [126023]|158||||158|9.64|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|158||||158|109.02|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|158||||158|10.51|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158||||158|8.41|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158||||158|11.5|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158||||158|7.06|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158||||158|8.41|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158||||158|11.5|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158||||158|7.06|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|158||||158|7.06|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|158||||158|109.02|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158||||158|7.06|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|Self-pay|Self-pay|158||||158|55.3|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|158||||158|7.06|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158||||158|7.06|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158||||158|11.74|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|158||||158|8.41|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|158||||158|8.41|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158||||158|11.74|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158||||158|8.41|109.02|7.06
30687102|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS OTHER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158||||158|16.82|109.02|7.06
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AARP [1000]|AARP [100000]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AETNA [1015]|AETNA [101529]|78||||78|27.98|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BCBS UTHCT [115568]|78||||78|36.66|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|78||||78|24.96|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|78||||78|39|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|78||||78|49.14|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|CIGNA [1260]|CIGNA GWH [126023]|78||||78|10.49|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|78||||78|53.82|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|78||||78|25.58|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|78||||78|27.98|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|78||||78|27.98|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|78||||78|53.82|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|Self-pay|Self-pay|78||||78|27.3|53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|78||||78||53.82|10.49
30687103|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS BLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|78||||78||53.82|10.49
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AARP [1000]|AARP [100000]|166||||166|14.42|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|166||||166|10.42|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AETNA [1015]|AETNA [101529]|166||||166|14.11|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|166||||166|8.67|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|166||||166|10.32|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|166||||166|10.32|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BCBS UTHCT [115568]|166||||166|78.02|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|166||||166|15.54|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|166||||166|83|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|166||||166|104.58|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|166||||166|8.67|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|166||||166|10.32|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|CIGNA [1260]|CIGNA GWH [126023]|166||||166|11.89|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|166||||166|114.54|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|166||||166|12.9|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|166||||166|10.32|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|166||||166|14.11|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|166||||166|8.67|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|166||||166|10.32|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|166||||166|14.11|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|166||||166|8.67|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|166||||166|8.67|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|166||||166|114.54|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|166||||166|8.67|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|Self-pay|Self-pay|166||||166|58.1|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|166||||166|8.67|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|166||||166|8.67|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|166||||166|14.42|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|166||||166|10.32|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|166||||166|10.32|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|166||||166|14.42|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|166||||166|10.32|114.54|8.67
30687106|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|166||||166|20.64|114.54|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|AARP [1000]|AARP [100000]|204||||204|14.42|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|10.42|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|AETNA [1015]|AETNA [101529]|204||||204|14.11|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|8.67|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|10.32|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|10.32|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|15.54|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|8.67|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|10.32|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|11.89|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|12.9|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|10.32|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|14.11|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|8.67|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|10.32|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|14.11|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|8.67|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|8.67|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|8.67|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|Self-pay|Self-pay|204||||204|71.4|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|8.67|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|8.67|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|14.42|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|10.32|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|10.32|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|14.42|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|10.32|140.76|8.67
30687107|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE FUNGUS ID MOLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|20.64|140.76|8.67
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|AARP [1000]|AARP [100000]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|AETNA [1015]|AETNA [101529]|50||||50|21.05|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|BCBS [1155]|BCBS UTHCT [115568]|50||||50|23.5|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50||||50|23.18|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50||||50|25|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50||||50|31.5|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|CIGNA [1260]|CIGNA GWH [126023]|50||||50|17.84|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|50||||50|34.5|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50||||50|19.24|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50||||50|21.05|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50||||50|21.05|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|50||||50|34.5|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|Self-pay|Self-pay|50||||50|17.5|34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50||||50||34.5|17.5
30687109|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOPLASMA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50||||50||34.5|17.5
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|AARP [1000]|AARP [100000]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|AETNA [1015]|AETNA [101529]|208||||208|26.81|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|BCBS [1155]|BCBS UTHCT [115568]|208||||208|97.76|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|208||||208|29.51|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|208||||208|104|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|208||||208|131.04|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|CIGNA [1260]|CIGNA GWH [126023]|208||||208|22.67|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|208||||208|143.52|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|208||||208|24.5|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|208||||208|26.81|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|208||||208|26.81|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|208||||208|143.52|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|Self-pay|Self-pay|208||||208|72.8|143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|208||||208||143.52|22.67
30687110|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE CHLAMYDIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|208||||208||143.52|22.67
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AARP [1000]|AARP [100000]|347||||347|15.1|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|347||||347|10.91|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AETNA [1015]|AETNA [101529]|347||||347|14.78|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|347||||347|9.07|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|347||||347|10.8|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|347||||347|10.8|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BCBS UTHCT [115568]|347||||347|163.09|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|347||||347|16.27|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|347||||347|173.5|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|347||||347|218.61|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|347||||347|9.07|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|347||||347|10.8|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|CIGNA [1260]|CIGNA GWH [126023]|347||||347|12.47|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|347||||347|239.43|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|347||||347|13.5|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|347||||347|10.8|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|347||||347|14.78|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|347||||347|9.07|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|347||||347|10.8|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|347||||347|14.78|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|347||||347|9.07|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|347||||347|9.07|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|347||||347|239.43|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|347||||347|9.07|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|Self-pay|Self-pay|347||||347|121.45|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|347||||347|9.07|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|347||||347|9.07|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|347||||347|15.1|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|347||||347|10.8|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|347||||347|10.8|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|347||||347|15.1|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|347||||347|10.8|239.43|9.07
30687116|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE AFB/TB/MYCOB ISO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|347||||347|21.6|239.43|9.07
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|AARP [1000]|AARP [100000]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|AETNA [1015]|AETNA [101529]|190||||190|19.99|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|BCBS [1155]|BCBS UTHCT [115568]|190||||190|89.3|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|190||||190|17.82|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|190||||190|95|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|190||||190|119.7|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|CIGNA [1260]|CIGNA GWH [126023]|190||||190|12.74|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|190||||190|131.1|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|190||||190|18.26|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|190||||190|19.99|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|190||||190|19.99|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|190||||190|131.1|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|Self-pay|Self-pay|190||||190|66.5|131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|190||||190||131.1|12.74
30687118|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE MYCOBACTERIA ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|190||||190||131.1|12.74
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|AARP [1000]|AARP [100000]|51||||51|7.79|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51||||51|5.63|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|AETNA [1015]|AETNA [101529]|51||||51|7.61|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51||||51|4.68|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51||||51|5.57|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51||||51|5.57|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|BCBS [1155]|BCBS UTHCT [115568]|51||||51|23.97|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51||||51|8.39|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51||||51|25.5|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51||||51|32.13|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51||||51|4.68|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51||||51|5.57|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|CIGNA [1260]|CIGNA GWH [126023]|51||||51|6.5|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|51||||51|35.19|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|51||||51|6.96|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51||||51|5.57|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51||||51|7.61|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51||||51|4.68|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51||||51|5.57|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51||||51|7.61|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51||||51|4.68|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|51||||51|4.68|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|51||||51|35.19|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51||||51|4.68|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|Self-pay|Self-pay|51||||51|17.85|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|51||||51|4.68|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51||||51|4.68|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51||||51|7.79|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|51||||51|5.57|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|51||||51|5.57|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51||||51|7.79|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51||||51|5.57|35.19|4.68
30687140|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING FLOUR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51||||51|11.14|35.19|4.68
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|AARP [1000]|AARP [100000]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|AETNA [1015]|AETNA [101529]|186.76||||186.76|7.08|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|BCBS [1155]|BCBS UTHCT [115568]|186.76||||186.76|87.78|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|186.76||||186.76|7.8|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|186.76||||186.76|93.38|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|186.76||||186.76|117.66|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|CIGNA [1260]|CIGNA GWH [126023]|186.76||||186.76|5.95|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|186.76||||186.76|128.86|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|186.76||||186.76|6.48|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|186.76||||186.76|7.08|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|186.76||||186.76|7.08|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|186.76||||186.76|128.86|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|Self-pay|Self-pay|186.76||||186.76|65.37|128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|186.76||||186.76||128.86|5.95
30687147|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING SEROLOGIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|186.76||||186.76||128.86|5.95
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|AARP [1000]|AARP [100000]|211||||211|28.02|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|211||||211|20.25|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|AETNA [1015]|AETNA [101529]|211||||211|27.43|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|211||||211|16.84|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|211||||211|20.05|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|211||||211|20.05|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|BCBS [1155]|BCBS UTHCT [115568]|211||||211|99.17|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|211||||211|30.21|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|211||||211|105.5|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|211||||211|132.93|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|211||||211|16.84|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|211||||211|20.05|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|CIGNA [1260]|CIGNA GWH [126023]|211||||211|23.23|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|211||||211|145.59|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|211||||211|25.06|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|211||||211|20.05|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|211||||211|27.43|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|211||||211|16.84|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|211||||211|20.05|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|211||||211|27.43|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|211||||211|16.84|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|211||||211|16.84|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|211||||211|145.59|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|211||||211|16.84|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|Self-pay|Self-pay|211||||211|73.85|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|211||||211|16.84|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|211||||211|16.84|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|211||||211|28.02|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|211||||211|20.05|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|211||||211|20.05|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|211||||211|28.02|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|211||||211|20.05|145.59|16.84
30687149|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING NUC ACID DIRECT PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|211||||211|40.1|145.59|16.84
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|AARP [1000]|AARP [100000]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|AETNA [1015]|AETNA [101529]|320||||320|48|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|BCBS [1155]|BCBS UTHCT [115568]|320||||320|150.4|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|320||||320|52.86|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|320||||320|160|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|320||||320|201.6|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|CIGNA [1260]|CIGNA GWH [126023]|320||||320|176|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|320||||320|220.8|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|320||||320|43.86|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|320||||320|48|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|320||||320|48|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|320||||320|220.8|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|Self-pay|Self-pay|320||||320|112|220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|320||||320||220.8|43.86
30687150|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULT TYPING NUC ACID PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|320||||320||220.8|43.86
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|AARP [1000]|AARP [100000]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|AETNA [1015]|AETNA [101529]|350||||350|10.58|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|BCBS [1155]|BCBS UTHCT [115568]|350||||350|164.5|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|350||||350|9.44|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|350||||350|175|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|350||||350|220.5|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|CIGNA [1260]|CIGNA GWH [126023]|350||||350|5.95|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|350||||350|241.5|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|350||||350|9.68|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|350||||350|10.58|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|350||||350|10.58|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|350||||350|241.5|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|Self-pay|Self-pay|350||||350|122.5|241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|350||||350||241.5|5.95
30687152|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE PULSE FIELD GEL ID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|350||||350||241.5|5.95
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|AARP [1000]|AARP [100000]|519.75||||519.75|165.22|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|519.75||||519.75|116.51|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|AETNA [1015]|AETNA [101529]|519.75||||519.75|157.82|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|519.75||||519.75|96.9|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|519.75||||519.75|115.36|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|519.75||||519.75|115.36|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|BCBS [1155]|BCBS UTHCT [115568]|519.75||||519.75|244.28|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|519.75||||519.75|173.75|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|519.75||||519.75|259.88|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|519.75||||519.75|327.44|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|519.75||||519.75|96.9|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|519.75||||519.75|115.36|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|CIGNA [1260]|CIGNA GWH [126023]|519.75||||519.75|285.86|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|519.75||||519.75|358.63|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|519.75||||519.75|144.2|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|519.75||||519.75|115.36|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|519.75||||519.75|157.82|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|519.75||||519.75|96.9|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|519.75||||519.75|115.36|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|519.75||||519.75|157.82|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|519.75||||519.75|96.9|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|519.75||||519.75|96.9|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|519.75||||519.75|358.63|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|519.75||||519.75|96.9|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|Self-pay|Self-pay|519.75||||519.75|181.91|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|519.75||||519.75|96.9|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|519.75||||519.75|96.9|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|519.75||||519.75|165.22|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|519.75||||519.75|115.36|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|519.75||||519.75|115.36|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|519.75||||519.75|165.22|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|519.75||||519.75|115.36|358.63|96.9
30687153|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE DNA RNA SEQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|519.75||||519.75|230.72|358.63|96.9
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|AARP [1000]|AARP [100000]|225||||225|7.31|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|225||||225|7.82|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|AETNA [1015]|AETNA [101529]|225||||225|10.58|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|225||||225|6.5|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|225||||225|7.74|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|225||||225|7.74|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|BCBS [1155]|BCBS UTHCT [115568]|225||||225|105.75|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|225||||225|9.44|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|225||||225|112.5|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|225||||225|141.75|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|225||||225|6.5|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|225||||225|7.74|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|CIGNA [1260]|CIGNA GWH [126023]|225||||225|5.95|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|225||||225|155.25|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|225||||225|9.68|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|225||||225|7.74|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|225||||225|10.58|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|225||||225|6.5|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|225||||225|7.74|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|225||||225|10.58|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|225||||225|6.5|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|225||||225|6.5|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|225||||225|155.25|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|225||||225|6.5|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|Self-pay|Self-pay|225||||225|78.75|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|225||||225|6.5|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|225||||225|6.5|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|225||||225|7.31|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|225||||225|7.74|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|225||||225|7.74|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|225||||225|7.31|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|225||||225|7.74|155.25|5.95
30687158|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CULTURE TYPING OTHER METHOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|225||||225|15.48|155.25|5.95
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|AARP [1000]|AARP [100000]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|AETNA [1015]|AETNA [101529]|12||||12|5.83|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|BCBS [1155]|BCBS UTHCT [115568]|12||||12|5.64|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12||||12|6.43|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12||||12|6|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12||||12|7.56|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|CIGNA [1260]|CIGNA GWH [126023]|12||||12|4.81|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12||||12|8.28|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12||||12|5.34|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12||||12|5.83|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12||||12|5.83|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12||||12|8.28|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|Self-pay|Self-pay|12||||12|4.2|8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12||||12||8.28|4.2
30687168|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM ARTHROPOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12||||12||8.28|4.2
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|AARP [1000]|AARP [100000]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|AETNA [1015]|AETNA [101529]|36||||36|5.9|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|BCBS [1155]|BCBS UTHCT [115568]|36||||36|16.92|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36||||36|6.43|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36||||36|18|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36||||36|22.68|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|CIGNA [1260]|CIGNA GWH [126023]|36||||36|4.81|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|36||||36|24.84|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|36||||36|5.39|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36||||36|5.9|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36||||36|5.9|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|36||||36|24.84|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|Self-pay|Self-pay|36||||36|12.6|24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36||||36||24.84|4.81
30687169|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MACROSCOPIC EXAM PARASITE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36||||36||24.84|4.81
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|AARP [1000]|AARP [100000]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|AETNA [1015]|AETNA [101529]|55||||55|8.04|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|BCBS [1155]|BCBS UTHCT [115568]|55||||55|25.85|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|55||||55|8.86|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|55||||55|27.5|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|55||||55|34.65|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|CIGNA [1260]|CIGNA GWH [126023]|55||||55|6.79|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|55||||55|37.95|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|55||||55|7.35|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55||||55|8.04|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55||||55|8.04|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|55||||55|37.95|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|Self-pay|Self-pay|55||||55|19.25|37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|55||||55||37.95|6.79
30687176|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENDOTOXIN HOMOGENIZATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|55||||55||37.95|6.79
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AARP [1000]|AARP [100000]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AETNA [1015]|AETNA [101529]|114||||114|12.17|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS [1155]|BCBS UTHCT [115568]|114||||114|53.58|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|114||||114|13.41|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|114||||114|57|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|114||||114|71.82|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|CIGNA [1260]|CIGNA GWH [126023]|114||||114|10.2|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|114||||114|78.66|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|114||||114|11.13|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|114||||114|12.17|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|114||||114|12.17|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|114||||114|78.66|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|Self-pay|Self-pay|114||||114|39.9|78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|114||||114||78.66|10.2
30687177|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR OVA & PARASITE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|114||||114||78.66|10.2
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AARP [1000]|AARP [100000]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AETNA [1015]|AETNA [101529]|392||||392|6.5|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BCBS UTHCT [115568]|392||||392|184.24|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|392||||392|7.15|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|392||||392|196|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|392||||392|246.96|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|CIGNA [1260]|CIGNA GWH [126023]|392||||392|5.39|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|392||||392|270.48|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|392||||392|5.94|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|392||||392|6.5|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|392||||392|6.5|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|392||||392|270.48|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|Self-pay|Self-pay|392||||392|137.2|270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|392||||392||270.48|5.39
30687181|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTBILTY STDY AGAR EA ANTIMICRBIAL AGNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|392||||392||270.48|5.39
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AARP [1000]|AARP [100000]|107.28||||107.28|9.63|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|107.28||||107.28|7.55|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AETNA [1015]|AETNA [101529]|107.28||||107.28|10.22|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|107.28||||107.28|6.28|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|107.28||||107.28|7.48|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|107.28||||107.28|7.48|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BCBS UTHCT [115568]|107.28||||107.28|50.42|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|107.28||||107.28|10.38|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|107.28||||107.28|53.64|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|107.28||||107.28|67.59|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|107.28||||107.28|6.28|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|107.28||||107.28|7.48|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|CIGNA [1260]|CIGNA GWH [126023]|107.28||||107.28|7.93|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|107.28||||107.28|74.02|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|107.28||||107.28|9.35|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|107.28||||107.28|7.48|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|107.28||||107.28|10.22|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|107.28||||107.28|6.28|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|107.28||||107.28|7.48|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|107.28||||107.28|10.22|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|107.28||||107.28|6.28|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|107.28||||107.28|6.28|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|107.28||||107.28|74.02|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|107.28||||107.28|6.28|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|Self-pay|Self-pay|107.28||||107.28|37.55|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|107.28||||107.28|6.28|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|107.28||||107.28|6.28|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|107.28||||107.28|9.63|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|107.28||||107.28|7.48|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|107.28||||107.28|7.48|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|107.28||||107.28|9.63|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|107.28||||107.28|7.48|74.02|6.28
30687184|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY STUDY ANTIMICROBIAL DISK METHOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|107.28||||107.28|14.96|74.02|6.28
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|AARP [1000]|AARP [100000]|49||||49|6.64|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49||||49|4.8|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|AETNA [1015]|AETNA [101529]|49||||49|6.5|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49||||49|3.99|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49||||49|4.75|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49||||49|4.75|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|BCBS [1155]|BCBS UTHCT [115568]|49||||49|23.03|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49||||49|7.15|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49||||49|24.5|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49||||49|30.87|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49||||49|3.99|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49||||49|4.75|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|CIGNA [1260]|CIGNA GWH [126023]|49||||49|5.39|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|49||||49|33.81|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|49||||49|5.94|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49||||49|4.75|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49||||49|6.5|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49||||49|3.99|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49||||49|4.75|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49||||49|6.5|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49||||49|3.99|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|49||||49|3.99|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|49||||49|33.81|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49||||49|3.99|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|Self-pay|Self-pay|49||||49|17.15|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|49||||49|3.99|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49||||49|3.99|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49||||49|6.64|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|49||||49|4.75|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|49||||49|4.75|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49||||49|6.64|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49||||49|4.75|33.81|3.99
30687185|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SUSCEPTIBILITY BETA LACTAMASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49||||49|9.5|33.81|3.99
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AARP [1000]|AARP [100000]|380||||380|12.08|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|380||||380|8.74|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AETNA [1015]|AETNA [101529]|380||||380|11.83|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|380||||380|7.27|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|380||||380|8.65|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|380||||380|8.65|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BCBS UTHCT [115568]|380||||380|178.6|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|380||||380|13.02|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|380||||380|190|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|380||||380|239.4|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|380||||380|7.27|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|380||||380|8.65|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|CIGNA [1260]|CIGNA GWH [126023]|380||||380|9.92|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|380||||380|262.2|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|380||||380|10.81|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|380||||380|8.65|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|380||||380|11.83|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|380||||380|7.27|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|380||||380|8.65|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|380||||380|11.83|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|380||||380|7.27|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|380||||380|7.27|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|380||||380|262.2|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|380||||380|7.27|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|Self-pay|Self-pay|380||||380|133|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|380||||380|7.27|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|380||||380|7.27|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|380||||380|12.08|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|380||||380|8.65|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|380||||380|8.65|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|380||||380|12.08|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|380||||380|8.65|262.2|7.27
30687186|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SENSITIVITY MIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|380||||380|17.3|262.2|7.27
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|AARP [1000]|AARP [100000]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|AETNA [1015]|AETNA [101529]|65||||65|9.07|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|BCBS [1155]|BCBS UTHCT [115568]|65||||65|30.55|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65||||65|10|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65||||65|32.5|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65||||65|40.95|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|CIGNA [1260]|CIGNA GWH [126023]|65||||65|7.64|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|65||||65|44.85|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65||||65|8.3|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65||||65|9.07|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65||||65|9.07|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|65||||65|44.85|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|Self-pay|Self-pay|65||||65|22.75|44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65||||65||44.85|7.64
30687188|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SC STD ANTMCRB AGT MACROBROTH DIL METH EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65||||65||44.85|7.64
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AARP [1000]|AARP [100000]|83||||83|5.96|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83||||83|4.31|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AETNA [1015]|AETNA [101529]|83||||83|5.83|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83||||83|3.59|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83||||83|4.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83||||83|4.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BCBS UTHCT [115568]|83||||83|39.01|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83||||83|6.43|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83||||83|41.5|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83||||83|52.29|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83||||83|3.59|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83||||83|4.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|CIGNA [1260]|CIGNA GWH [126023]|83||||83|7.7|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|83||||83|57.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|83||||83|5.34|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83||||83|4.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83||||83|5.83|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83||||83|3.59|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83||||83|4.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83||||83|5.83|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83||||83|3.59|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|83||||83|3.59|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|83||||83|57.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83||||83|3.59|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|Self-pay|Self-pay|83||||83|29.05|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|83||||83|3.59|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83||||83|3.59|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83||||83|5.96|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|83||||83|4.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|83||||83|4.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83||||83|5.96|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83||||83|4.27|57.27|3.59
30687205|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR GRAM STAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83||||83|8.54|57.27|3.59
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AARP [1000]|AARP [100000]|138||||138|7.5|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138||||138|5.44|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AETNA [1015]|AETNA [101529]|138||||138|7.37|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138||||138|4.53|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138||||138|5.39|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138||||138|5.39|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BCBS UTHCT [115568]|138||||138|64.86|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138||||138|8.11|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138||||138|69|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138||||138|86.94|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138||||138|4.53|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138||||138|5.39|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|CIGNA [1260]|CIGNA GWH [126023]|138||||138|6.24|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|138||||138|95.22|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138||||138|6.74|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138||||138|5.39|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138||||138|7.37|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138||||138|4.53|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138||||138|5.39|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138||||138|7.37|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138||||138|4.53|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|138||||138|4.53|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|138||||138|95.22|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138||||138|4.53|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|Self-pay|Self-pay|138||||138|48.3|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138||||138|4.53|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138||||138|4.53|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138||||138|7.5|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138||||138|5.39|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138||||138|5.39|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138||||138|7.5|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138||||138|5.39|95.22|4.53
30687206|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR FLUORESCENT &/OR AFS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138||||138|10.78|95.22|4.53
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|AARP [1000]|AARP [100000]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|AETNA [1015]|AETNA [101529]|60||||60|8.18|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|BCBS [1155]|BCBS UTHCT [115568]|60||||60|28.2|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60||||60|9.03|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60||||60|30|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60||||60|37.8|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|CIGNA [1260]|CIGNA GWH [126023]|60||||60|32.76|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|60||||60|41.4|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|60||||60|7.49|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60||||60|8.18|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60||||60|8.18|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|60||||60|41.4|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|Self-pay|Self-pay|60||||60|21|41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60||||60||41.4|7.49
30687207|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR PRIM SRC SPEC STAIN BODIES/PARASITS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60||||60||41.4|7.49
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AARP [1000]|AARP [100000]|254||||254|25.11|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|254||||254|18.16|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AETNA [1015]|AETNA [101529]|254||||254|24.6|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|254||||254|15.1|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|254||||254|17.98|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|254||||254|17.98|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS [1155]|BCBS UTHCT [115568]|254||||254|119.38|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|254||||254|27.07|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|254||||254|127|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|254||||254|160.02|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|254||||254|15.1|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|254||||254|17.98|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|CIGNA [1260]|CIGNA GWH [126023]|254||||254|33.54|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|GROUP PENSION ADMIN [1450]|GPA [145000]|254||||254|175.26|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|254||||254|22.48|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|254||||254|17.98|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|254||||254|24.6|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|254||||254|15.1|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|254||||254|17.98|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|254||||254|24.6|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|254||||254|15.1|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|254||||254|15.1|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|PHCS [1780]|PHCS MULTIPLAN [178000]|254||||254|175.26|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|254||||254|15.1|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|Self-pay|Self-pay|254||||254|88.9|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|254||||254|15.1|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|254||||254|15.1|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|254||||254|25.11|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|254||||254|17.98|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|254||||254|17.98|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|254||||254|25.11|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|254||||254|17.98|175.26|15.1
30687209|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHROME ST FOR O&P|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|254||||254|35.96|175.26|15.1
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AARP [1000]|AARP [100000]|129||||129|5.96|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129||||129|5.88|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AETNA [1015]|AETNA [101529]|129||||129|7.97|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129||||129|4.89|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129||||129|5.82|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129||||129|5.82|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS [1155]|BCBS UTHCT [115568]|129||||129|60.63|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129||||129|7.1|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129||||129|64.5|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129||||129|81.27|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129||||129|4.89|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129||||129|5.82|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|CIGNA [1260]|CIGNA GWH [126023]|129||||129|7.7|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|129||||129|89.01|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|129||||129|7.28|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129||||129|5.82|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129||||129|7.97|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129||||129|4.89|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129||||129|5.82|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129||||129|7.97|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129||||129|4.89|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|129||||129|4.89|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|129||||129|89.01|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129||||129|4.89|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|Self-pay|Self-pay|129||||129|45.15|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|129||||129|4.89|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129||||129|4.89|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129||||129|5.96|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|129||||129|5.82|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|129||||129|5.82|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129||||129|5.96|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129||||129|5.82|89.01|4.89
30687210|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC SMEAR WET MOUNT W/STAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129||||129|11.64|89.01|4.89
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|AARP [1000]|AARP [100000]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|AETNA [1015]|AETNA [101529]|168||||168|5.83|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|BCBS [1155]|BCBS UTHCT [115568]|168||||168|78.96|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|168||||168|6.43|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|168||||168|84|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|168||||168|105.84|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|CIGNA [1260]|CIGNA GWH [126023]|168||||168|7.7|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|168||||168|115.92|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|168||||168|5.34|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|168||||168|5.83|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|168||||168|5.83|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|168||||168|115.92|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|Self-pay|Self-pay|168||||168|58.8|115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|168||||168||115.92|5.34
30687220|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TISSUE EXAM FUNGUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|168||||168||115.92|5.34
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|AARP [1000]|AARP [100000]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|AETNA [1015]|AETNA [101529]|136||||136|27|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|BCBS [1155]|BCBS UTHCT [115568]|136||||136|63.92|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136||||136|29.73|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136||||136|68|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136||||136|85.68|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|CIGNA [1260]|CIGNA GWH [126023]|136||||136|22.94|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|136||||136|93.84|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|136||||136|24.68|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136||||136|27|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136||||136|27|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|136||||136|93.84|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|Self-pay|Self-pay|136||||136|47.6|93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136||||136||93.84|22.94
30687230|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TOXIN/ANTI ASSAY C DIFFICILE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136||||136||93.84|22.94
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AARP [1000]|AARP [100000]|354||||354|36.42|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|354||||354|26.33|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AETNA [1015]|AETNA [101529]|354||||354|35.66|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|354||||354|21.9|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|354||||354|26.07|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|354||||354|26.07|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BCBS UTHCT [115568]|354||||354|166.38|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|354||||354|39.26|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|354||||354|177|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|354||||354|223.02|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|354||||354|21.9|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|354||||354|26.07|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|CIGNA [1260]|CIGNA GWH [126023]|354||||354|30.31|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|354||||354|244.26|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|354||||354|32.59|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|354||||354|26.07|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|354||||354|35.66|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|354||||354|21.9|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|354||||354|26.07|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|354||||354|35.66|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|354||||354|21.9|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|354||||354|21.9|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|354||||354|244.26|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|354||||354|21.9|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|Self-pay|Self-pay|354||||354|123.9|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|354||||354|21.9|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|354||||354|21.9|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|354||||354|36.42|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|354||||354|26.07|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|354||||354|26.07|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|354||||354|36.42|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|354||||354|26.07|244.26|21.9
30687252|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISO TISSUE INOCULATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|354||||354|52.14|244.26|21.9
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|AARP [1000]|AARP [100000]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|AETNA [1015]|AETNA [101529]|393||||393|27.62|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|BCBS [1155]|BCBS UTHCT [115568]|393||||393|184.71|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|393||||393|30.43|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|393||||393|196.5|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|393||||393|247.59|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|CIGNA [1260]|CIGNA GWH [126023]|393||||393|23.52|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|393||||393|271.17|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|393||||393|25.25|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|393||||393|27.62|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|393||||393|27.62|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|393||||393|271.17|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|Self-pay|Self-pay|393||||393|137.55|271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|393||||393||271.17|23.52
30687253|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS TISSUE CULTURE ADDL STDY/ID EACH ISOLATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|393||||393||271.17|23.52
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AARP [1000]|AARP [100000]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AETNA [1015]|AETNA [101529]|95||||95|26.76|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS [1155]|BCBS UTHCT [115568]|95||||95|44.65|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|95||||95|29.46|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|95||||95|47.5|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|95||||95|59.85|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|CIGNA [1260]|CIGNA GWH [126023]|95||||95|22.67|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|95||||95|65.55|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|95||||95|24.45|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95||||95|26.76|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95||||95|26.76|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|95||||95|65.55|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|Self-pay|Self-pay|95||||95|33.25|65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95||||95||65.55|22.67
30687254|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC VIRUS ISOL CENTRI ENHANCED EA VIRUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|95||||95||65.55|22.67
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AARP [1000]|AARP [100000]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AETNA [1015]|AETNA [101529]|20||||20|19.75|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS [1155]|BCBS UTHCT [115568]|20||||20|9.4|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|18.06|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|10|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|12.6|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|CIGNA [1260]|CIGNA GWH [126023]|20||||20|13.88|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20||||20|18.04|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|19.75|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|19.75|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|Self-pay|Self-pay|20||||20|7|19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20||19.75|7
30687260|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF ADENOVIRUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20||||20||19.75|7
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|AARP [1000]|AARP [100000]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|AETNA [1015]|AETNA [101529]|34||||34|16.39|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|BCBS [1155]|BCBS UTHCT [115568]|34||||34|15.98|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|18.06|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|21.42|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|CIGNA [1260]|CIGNA GWH [126023]|34||||34|13.88|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34||||34|14.98|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|16.39|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|16.39|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|Self-pay|Self-pay|34||||34|11.9|23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34||23.46|11.9
30687273|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERP SIMPLEX TYPE II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|AARP [1000]|AARP [100000]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|AETNA [1015]|AETNA [101529]|34||||34|16.39|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|BCBS [1155]|BCBS UTHCT [115568]|34||||34|15.98|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|18.06|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|21.42|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|CIGNA [1260]|CIGNA GWH [126023]|34||||34|13.88|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34||||34|14.98|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|16.39|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|16.39|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|Self-pay|Self-pay|34||||34|11.9|23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34||23.46|11.9
30687274|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA HERPES SIMPLEX TYPE I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34||23.46|11.9
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AARP [1000]|AARP [100000]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AETNA [1015]|AETNA [101529]|223||||223|16.75|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS [1155]|BCBS UTHCT [115568]|223||||223|104.81|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|223||||223|18.06|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|223||||223|111.5|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|223||||223|140.49|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|CIGNA [1260]|CIGNA GWH [126023]|223||||223|13.88|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|GROUP PENSION ADMIN [1450]|GPA [145000]|223||||223|153.87|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|223||||223|15.31|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|223||||223|16.75|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|223||||223|16.75|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|PHCS [1780]|PHCS MULTIPLAN [178000]|223||||223|153.87|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|Self-pay|Self-pay|223||||223|78.05|153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|223||||223||153.87|13.88
30687275|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA INFLUENZA B|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AARP [1000]|AARP [100000]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AETNA [1015]|AETNA [101529]|223||||223|21.98|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS [1155]|BCBS UTHCT [115568]|223||||223|104.81|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|223||||223|19.61|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|223||||223|111.5|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|223||||223|140.49|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|CIGNA [1260]|CIGNA GWH [126023]|223||||223|13.88|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|GROUP PENSION ADMIN [1450]|GPA [145000]|223||||223|153.87|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|223||||223|20.09|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|223||||223|21.98|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|223||||223|21.98|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|PHCS [1780]|PHCS MULTIPLAN [178000]|223||||223|153.87|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|Self-pay|Self-pay|223||||223|78.05|153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|223||||223||153.87|13.88
30687276|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF INFLUENZA A|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|223||||223||153.87|13.88
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AARP [1000]|AARP [100000]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AETNA [1015]|AETNA [101529]|20||||20|20|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS [1155]|BCBS UTHCT [115568]|20||||20|9.4|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|20|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|10|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|12.6|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|CIGNA [1260]|CIGNA GWH [126023]|20||||20|13.88|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20||||20|20.54|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|20|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|20|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|Self-pay|Self-pay|20||||20|7|20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20||20.54|7
30687279|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF PARAINFLUENZA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20||||20||20.54|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AARP [1000]|AARP [100000]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AETNA [1015]|AETNA [101529]|20||||20|18.36|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS [1155]|BCBS UTHCT [115568]|20||||20|9.4|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20||||20|18.06|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20||||20|10|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20||||20|12.6|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|CIGNA [1260]|CIGNA GWH [126023]|20||||20|13.88|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|20||||20|13.8|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20||||20|16.78|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20||||20|18.36|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20||||20|18.36|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|20||||20|13.8|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|Self-pay|Self-pay|20||||20|7|18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20||||20||18.36|7
30687280|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IF RSV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20||||20||18.36|7
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AARP [1000]|AARP [100000]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AETNA [1015]|AETNA [101529]|303||||303|16.39|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS [1155]|BCBS UTHCT [115568]|303||||303|142.41|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|303||||303|18.06|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|303||||303|151.5|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|303||||303|190.89|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|CIGNA [1260]|CIGNA GWH [126023]|303||||303|13.88|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|303||||303|209.07|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|303||||303|14.98|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|303||||303|16.39|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|303||||303|16.39|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|303||||303|209.07|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|Self-pay|Self-pay|303||||303|106.05|209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|303||||303||209.07|13.88
30687281|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PNEUMOCYSTIS CARINII AG IF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|303||||303||209.07|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|AARP [1000]|AARP [100000]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|AETNA [1015]|AETNA [101529]|85||||85|18.36|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|BCBS [1155]|BCBS UTHCT [115568]|85||||85|39.95|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|85||||85|18.06|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|85||||85|42.5|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|85||||85|53.55|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|CIGNA [1260]|CIGNA GWH [126023]|85||||85|13.88|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|GROUP PENSION ADMIN [1450]|GPA [145000]|85||||85|58.65|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|85||||85|16.78|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|85||||85|18.36|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|85||||85|18.36|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|PHCS [1780]|PHCS MULTIPLAN [178000]|85||||85|58.65|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|Self-pay|Self-pay|85||||85|29.75|58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|85||||85||58.65|13.88
30687290|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DFA VARICELLA Z|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|85||||85||58.65|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AARP [1000]|AARP [100000]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AETNA [1015]|AETNA [101529]|138||||138|22.03|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS [1155]|BCBS UTHCT [115568]|138||||138|64.86|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138||||138|19.64|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138||||138|69|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138||||138|86.94|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|CIGNA [1260]|CIGNA GWH [126023]|138||||138|13.88|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|138||||138|95.22|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138||||138|20.13|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138||||138|22.03|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138||||138|22.03|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|138||||138|95.22|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|Self-pay|Self-pay|138||||138|48.3|95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138||||138||95.22|13.88
30687299|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG DETECT NOS IF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138||||138||95.22|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|AARP [1000]|AARP [100000]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|AETNA [1015]|AETNA [101529]|54||||54|16.39|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|BCBS [1155]|BCBS UTHCT [115568]|54||||54|25.38|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54||||54|18.06|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54||||54|27|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54||||54|34.02|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|CIGNA [1260]|CIGNA GWH [126023]|54||||54|13.88|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54||||54|37.26|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54||||54|14.98|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54||||54|16.39|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54||||54|16.39|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54||||54|37.26|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|Self-pay|Self-pay|54||||54|18.9|37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54||||54||37.26|13.88
30687301|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL ADENOVIRUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54||||54||37.26|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AARP [1000]|AARP [100000]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AETNA [1015]|AETNA [101529]|179||||179|16.39|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS [1155]|BCBS UTHCT [115568]|179||||179|84.13|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|179||||179|18.06|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|179||||179|89.5|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|179||||179|112.77|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|CIGNA [1260]|CIGNA GWH [126023]|179||||179|13.88|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|179||||179|123.51|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|179||||179|14.98|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|179||||179|16.39|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|179||||179|16.39|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|179||||179|123.51|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|Self-pay|Self-pay|179||||179|62.65|123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|179||||179||123.51|13.88
30687305|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ASPERGILLUS ANTIGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|179||||179||123.51|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AARP [1000]|AARP [100000]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AETNA [1015]|AETNA [101529]|58||||58|18.91|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS [1155]|BCBS UTHCT [115568]|58||||58|27.26|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58||||58|18.06|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58||||58|29|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58||||58|36.54|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|CIGNA [1260]|CIGNA GWH [126023]|58||||58|13.88|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|58||||58|40.02|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58||||58|17.28|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58||||58|18.91|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58||||58|18.91|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|58||||58|40.02|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|Self-pay|Self-pay|58||||58|20.3|40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58||||58||40.02|13.88
30687328|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA CRYPTOSPORIDIUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58||||58||40.02|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|AARP [1000]|AARP [100000]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|AETNA [1015]|AETNA [101529]|170||||170|16.39|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|BCBS [1155]|BCBS UTHCT [115568]|170||||170|79.9|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170||||170|18.06|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170||||170|85|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170||||170|107.1|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|CIGNA [1260]|CIGNA GWH [126023]|170||||170|13.88|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|170||||170|117.3|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|170||||170|14.98|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170||||170|16.39|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170||||170|16.39|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|170||||170|117.3|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|Self-pay|Self-pay|170||||170|59.5|117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170||||170||117.3|13.88
30687329|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA GIARDIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|170||||170||117.3|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|AARP [1000]|AARP [100000]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|AETNA [1015]|AETNA [101529]|63||||63|16.39|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|BCBS [1155]|BCBS UTHCT [115568]|63||||63|29.61|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63||||63|18.06|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63||||63|31.5|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63||||63|39.69|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|CIGNA [1260]|CIGNA GWH [126023]|63||||63|13.88|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63||||63|43.47|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63||||63|14.98|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63||||63|16.39|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63||||63|16.39|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63||||63|43.47|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|Self-pay|Self-pay|63||||63|22.05|43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63||||63||43.47|13.88
30687337|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC DETECT ENTAMOEBA HISTO ANTI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63||||63||43.47|13.88
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|AARP [1000]|AARP [100000]|220||||220|20.1|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|220||||220|14.52|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|AETNA [1015]|AETNA [101529]|220||||220|19.68|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|220||||220|12.08|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|220||||220|14.38|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|220||||220|14.38|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|BCBS [1155]|BCBS UTHCT [115568]|220||||220|103.4|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|220||||220|21.67|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|220||||220|110|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|220||||220|138.6|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|220||||220|12.08|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|220||||220|14.38|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|CIGNA [1260]|CIGNA GWH [126023]|220||||220|16.72|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|220||||220|151.8|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|220||||220|17.98|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|220||||220|14.38|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|220||||220|19.68|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|220||||220|12.08|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|220||||220|14.38|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|220||||220|19.68|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|220||||220|12.08|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|220||||220|12.08|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|220||||220|151.8|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|220||||220|12.08|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|Self-pay|Self-pay|220||||220|77|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|220||||220|12.08|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|220||||220|12.08|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|220||||220|20.1|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|220||||220|14.38|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|220||||220|14.38|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|220||||220|20.1|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|220||||220|14.38|151.8|12.08
30687338|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC H PYLORI AG EIA STOOL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|220||||220|28.76|151.8|12.08
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AARP [1000]|AARP [100000]|165||||165|14.43|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|165||||165|10.43|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AETNA [1015]|AETNA [101529]|165||||165|14.14|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|165||||165|8.68|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|165||||165|10.33|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|165||||165|10.33|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BCBS UTHCT [115568]|165||||165|77.55|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|165||||165|15.56|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|165||||165|82.5|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|165||||165|103.95|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|165||||165|8.68|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|165||||165|10.33|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|CIGNA [1260]|CIGNA GWH [126023]|165||||165|11.89|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|165||||165|113.85|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|165||||165|12.91|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|165||||165|10.33|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|165||||165|14.14|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|165||||165|8.68|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|165||||165|10.33|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|165||||165|14.14|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|165||||165|8.68|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|165||||165|8.68|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|165||||165|113.85|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|165||||165|8.68|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|Self-pay|Self-pay|165||||165|57.75|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|165||||165|8.68|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|165||||165|8.68|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|165||||165|14.43|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|165||||165|10.33|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|165||||165|10.33|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|165||||165|14.43|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|165||||165|10.33|113.85|8.68
30687340|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL HEP B AG (HBSAG)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|165||||165|20.66|113.85|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AARP [1000]|AARP [100000]|120||||120|14.43|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|120||||120|10.43|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AETNA [1015]|AETNA [101529]|120||||120|14.14|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|120||||120|8.68|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|120||||120|10.33|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|120||||120|10.33|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS [1155]|BCBS UTHCT [115568]|120||||120|56.4|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|120||||120|15.56|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|120||||120|60|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|120||||120|75.6|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|120||||120|8.68|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|120||||120|10.33|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|CIGNA [1260]|CIGNA GWH [126023]|120||||120|11.89|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|120||||120|82.8|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|120||||120|12.91|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|120||||120|10.33|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|120||||120|14.14|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|120||||120|8.68|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|120||||120|10.33|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|120||||120|14.14|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|120||||120|8.68|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|120||||120|8.68|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|120||||120|82.8|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|120||||120|8.68|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|Self-pay|Self-pay|120||||120|42|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|120||||120|8.68|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|120||||120|8.68|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|120||||120|14.43|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|120||||120|10.33|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|120||||120|10.33|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|120||||120|14.43|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|120||||120|10.33|82.8|8.68
30687341|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B SURFACE AG NEUTRALIZATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|120||||120|20.66|82.8|8.68
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AARP [1000]|AARP [100000]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AETNA [1015]|AETNA [101529]|215||||215|15.77|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS [1155]|BCBS UTHCT [115568]|215||||215|101.05|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|215||||215|17.36|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|215||||215|107.5|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|215||||215|135.45|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|CIGNA [1260]|CIGNA GWH [126023]|215||||215|13.32|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|215||||215|148.35|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|215||||215|14.41|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|215||||215|15.77|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|215||||215|15.77|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|215||||215|148.35|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|Self-pay|Self-pay|215||||215|75.25|148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|215||||215||148.35|13.32
30687350|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HEPATITIS BE ANTIGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|215||||215||148.35|13.32
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AARP [1000]|AARP [100000]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AETNA [1015]|AETNA [101529]|220||||220|18.12|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BCBS UTHCT [115568]|220||||220|103.4|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|220||||220|18.06|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|220||||220|110|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|220||||220|138.6|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|CIGNA [1260]|CIGNA GWH [126023]|220||||220|13.88|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|220||||220|151.8|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|220||||220|16.56|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|220||||220|18.12|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|220||||220|18.12|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|220||||220|151.8|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|Self-pay|Self-pay|220||||220|77|151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|220||||220||151.8|13.88
30687385|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA HISTOPLASM CAPSULATUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|220||||220||151.8|13.88
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|AARP [1000]|AARP [100000]|128||||128|34.12|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128||||128|24.32|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|AETNA [1015]|AETNA [101529]|128||||128|32.95|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128||||128|20.23|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128||||128|24.08|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128||||128|24.08|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|BCBS [1155]|BCBS UTHCT [115568]|128||||128|60.16|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128||||128|36.27|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128||||128|64|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128||||128|80.64|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128||||128|20.23|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128||||128|24.08|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|CIGNA [1260]|CIGNA GWH [126023]|128||||128|70.4|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|128||||128|88.32|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|128||||128|30.1|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128||||128|24.08|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128||||128|32.95|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128||||128|20.23|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128||||128|24.08|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128||||128|32.95|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128||||128|20.23|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|128||||128|20.23|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|128||||128|88.32|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128||||128|20.23|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|Self-pay|Self-pay|128||||128|44.8|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|128||||128|20.23|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128||||128|20.23|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128||||128|34.12|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|128||||128|24.08|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|128||||128|24.08|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128||||128|34.12|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128||||128|24.08|88.32|20.23
30687389|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HIV1 AG EIA HIV1/HIV2 AB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128||||128|48.16|88.32|20.23
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|AARP [1000]|AARP [100000]|219||||219|16.76|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|219||||219|14.05|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|AETNA [1015]|AETNA [101529]|219||||219|19.03|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|219||||219|11.68|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|219||||219|13.91|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|219||||219|13.91|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|BCBS [1155]|BCBS UTHCT [115568]|219||||219|102.93|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|219||||219|18.06|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|219||||219|109.5|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|219||||219|137.97|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|219||||219|11.68|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|219||||219|13.91|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|CIGNA [1260]|CIGNA GWH [126023]|219||||219|13.88|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|219||||219|151.11|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|219||||219|17.39|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|219||||219|13.91|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|219||||219|19.03|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|219||||219|11.68|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|219||||219|13.91|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|219||||219|19.03|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|219||||219|11.68|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|219||||219|11.68|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|219||||219|151.11|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|219||||219|11.68|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|Self-pay|Self-pay|219||||219|76.65|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|219||||219|11.68|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|219||||219|11.68|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|219||||219|16.76|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|219||||219|13.91|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|219||||219|13.91|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|219||||219|16.76|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|219||||219|13.91|151.11|11.68
30687420|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG EIA QL RSV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|219||||219|27.82|151.11|11.68
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|AARP [1000]|AARP [100000]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|AETNA [1015]|AETNA [101529]|225||||225|16.39|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|BCBS [1155]|BCBS UTHCT [115568]|225||||225|105.75|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|225||||225|18.06|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|225||||225|112.5|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|225||||225|141.75|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|CIGNA [1260]|CIGNA GWH [126023]|225||||225|13.88|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|225||||225|155.25|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|225||||225|14.98|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|225||||225|16.39|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|225||||225|16.39|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|225||||225|155.25|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|Self-pay|Self-pay|225||||225|78.75|155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|225||||225||155.25|13.88
30687425|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC AG IA ROTAVIRUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|225||||225||155.25|13.88
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|AARP [1000]|AARP [100000]|54||||54|16.76|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|54||||54|12.1|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|AETNA [1015]|AETNA [101529]|54||||54|16.39|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|54||||54|10.06|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|54||||54|11.98|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|54||||54|11.98|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|BCBS [1155]|BCBS UTHCT [115568]|54||||54|25.38|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|54||||54|18.06|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|54||||54|27|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|54||||54|34.02|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|54||||54|10.06|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|54||||54|11.98|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|CIGNA [1260]|CIGNA GWH [126023]|54||||54|13.88|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|54||||54|37.26|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|54||||54|14.98|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|54||||54|11.98|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|54||||54|16.39|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|54||||54|10.06|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|54||||54|11.98|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|54||||54|16.39|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|54||||54|10.06|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|54||||54|10.06|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|54||||54|37.26|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|54||||54|10.06|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|Self-pay|Self-pay|54||||54|18.9|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|54||||54|10.06|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|54||||54|10.06|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|54||||54|16.76|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|54||||54|11.98|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|54||||54|11.98|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|54||||54|16.76|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|54||||54|11.98|37.26|10.06
30687427|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG SHIGA-LIKE TOXIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|54||||54|23.96|37.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AARP [1000]|AARP [100000]|254||||254|16.76|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|254||||254|12.1|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AETNA [1015]|AETNA [101529]|254||||254|16.39|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|254||||254|10.06|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|254||||254|11.98|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|254||||254|11.98|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BCBS UTHCT [115568]|254||||254|119.38|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|254||||254|18.06|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|254||||254|127|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|254||||254|160.02|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|254||||254|10.06|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|254||||254|11.98|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|CIGNA [1260]|CIGNA GWH [126023]|254||||254|22.2|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|254||||254|175.26|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|254||||254|14.98|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|254||||254|11.98|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|254||||254|16.39|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|254||||254|10.06|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|254||||254|11.98|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|254||||254|16.39|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|254||||254|10.06|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|254||||254|10.06|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|254||||254|175.26|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|254||||254|10.06|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|Self-pay|Self-pay|254||||254|88.9|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|254||||254|10.06|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|254||||254|10.06|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|254||||254|16.76|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|254||||254|11.98|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|254||||254|11.98|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|254||||254|16.76|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|254||||254|11.98|175.26|10.06
30687449|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA AG DETECT MULTI-STEP NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|254||||254|23.96|175.26|10.06
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|AARP [1000]|AARP [100000]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|AETNA [1015]|AETNA [101529]|104||||104|14.33|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104||||104|30.84|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|BCBS [1155]|BCBS UTHCT [115568]|104||||104|48.88|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104||||104|52|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104||||104|52|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104||||104|65.52|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104||||104|30.84|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|CIGNA [1260]|CIGNA GWH [126023]|104||||104|11.04|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104||||104|71.76|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|104||||104|52|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104||||104|14.33|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104||||104|30.84|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104||||104|14.33|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104||||104|30.84|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|104||||104|30.84|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104||||104|71.76|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104||||104|30.84|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|Self-pay|Self-pay|104||||104|36.4|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|104||||104|30.84|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104||||104|30.84|71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104||||104||71.76|11.04
30687450|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IAAD IA SINGLE STEP METHOD NOS EA ORGANISM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104||||104||71.76|11.04
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|AARP [1000]|AARP [100000]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|AETNA [1015]|AETNA [101529]|123||||123|48|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|BCBS [1155]|BCBS UTHCT [115568]|123||||123|57.81|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|123||||123|52.86|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|123||||123|61.5|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|123||||123|77.49|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|CIGNA [1260]|CIGNA GWH [126023]|123||||123|40.8|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|123||||123|84.87|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|123||||123|43.86|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|123||||123|48|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|123||||123|48|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|123||||123|84.87|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|Self-pay|Self-pay|123||||123|43.05|84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|123||||123||84.87|40.8
30687476|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP BORRELIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|123||||123||84.87|40.8
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|AARP [1000]|AARP [100000]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|AETNA [1015]|AETNA [101529]|585||||585|570.14|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|585||||585|173.45|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|BCBS [1155]|BCBS UTHCT [115568]|585||||585|274.95|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|585||||585|585|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|585||||585|292.5|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|585||||585|368.55|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|585||||585|173.45|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|CIGNA [1260]|CIGNA GWH [126023]|585||||585|321.75|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|GROUP PENSION ADMIN [1450]|GPA [145000]|585||||585|403.65|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|585||||585|520.98|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|585||||585|570.14|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|585||||585|173.45|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|585||||585|570.14|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|585||||585|173.45|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|585||||585|173.45|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|PHCS [1780]|PHCS MULTIPLAN [178000]|585||||585|403.65|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|585||||585|173.45|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|Self-pay|Self-pay|585||||585|204.75|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|585||||585|173.45|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|585||||585|173.45|585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|585||||585||585|173.45
30687483|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC CNS DNA/RNA AMP PROBE MULTIPLE SUBTYPES 12-25|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|585||||585||585|173.45
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AARP [1000]|AARP [100000]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AETNA [1015]|AETNA [101529]|512||||512|48|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS [1155]|BCBS UTHCT [115568]|512||||512|240.64|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|512||||512|52.86|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|512||||512|256|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|512||||512|322.56|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|CIGNA [1260]|CIGNA GWH [126023]|512||||512|40.8|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|512||||512|353.28|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|512||||512|43.86|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|512||||512|48|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|512||||512|48|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|512||||512|353.28|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|Self-pay|Self-pay|512||||512|179.2|353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|512||||512||353.28|40.8
30687486|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA CHLYMD PNEUM DNA AMP PROBE TQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|512||||512||353.28|40.8
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AARP [1000]|AARP [100000]|239||||239|49.04|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|239||||239|35.44|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AETNA [1015]|AETNA [101529]|239||||239|48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|239||||239|29.48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|239||||239|35.09|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|239||||239|35.09|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS [1155]|BCBS UTHCT [115568]|239||||239|112.33|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|239||||239|52.86|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|239||||239|119.5|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|239||||239|150.57|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|239||||239|29.48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|239||||239|35.09|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|CIGNA [1260]|CIGNA GWH [126023]|239||||239|40.8|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|GROUP PENSION ADMIN [1450]|GPA [145000]|239||||239|164.91|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|239||||239|43.86|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|239||||239|35.09|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|239||||239|48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|239||||239|29.48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|239||||239|35.09|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|239||||239|48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|239||||239|29.48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|239||||239|29.48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|PHCS [1780]|PHCS MULTIPLAN [178000]|239||||239|164.91|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|239||||239|29.48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|Self-pay|Self-pay|239||||239|83.65|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|239||||239|29.48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|239||||239|29.48|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|239||||239|49.04|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|239||||239|35.09|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|239||||239|35.09|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|239||||239|49.04|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|239||||239|35.09|164.91|29.48
30687491|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP CHLAMYD T|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|239||||239|70.18|164.91|29.48
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AARP [1000]|AARP [100000]|336||||336|50.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|336||||336|37.64|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AETNA [1015]|AETNA [101529]|336||||336|50.98|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|336||||336|31.31|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|336||||336|37.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|336||||336|37.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BCBS UTHCT [115568]|336||||336|157.92|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|336||||336|52.86|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|336||||336|168|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|336||||336|211.68|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|336||||336|31.31|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|336||||336|37.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|CIGNA [1260]|CIGNA GWH [126023]|336||||336|184.8|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|336||||336|231.84|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|336||||336|46.59|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|336||||336|37.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|336||||336|50.98|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|336||||336|31.31|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|336||||336|37.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|336||||336|50.98|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|336||||336|31.31|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|336||||336|31.31|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|336||||336|231.84|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|336||||336|31.31|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|Self-pay|Self-pay|336||||336|117.6|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|336||||336|31.31|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|336||||336|31.31|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|336||||336|50.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|336||||336|37.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|336||||336|37.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|336||||336|50.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|336||||336|37.27|231.84|31.31
30687493|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP C DIFF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|336||||336|74.54|231.84|31.31
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|AARP [1000]|AARP [100000]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|AETNA [1015]|AETNA [101529]|639||||639|48|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|BCBS [1155]|BCBS UTHCT [115568]|639||||639|300.33|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|639||||639|52.86|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|639||||639|319.5|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|639||||639|402.57|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|CIGNA [1260]|CIGNA GWH [126023]|639||||639|40.8|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|639||||639|440.91|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|639||||639|43.86|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|639||||639|48|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|639||||639|48|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|639||||639|440.91|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|Self-pay|Self-pay|639||||639|223.65|440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|639||||639||440.91|40.8
30687496|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV AMP PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|639||||639||440.91|40.8
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AARP [1000]|AARP [100000]|476||||476|59.85|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|476||||476|43.27|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AETNA [1015]|AETNA [101529]|476||||476|58.61|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|476||||476|35.99|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|476||||476|42.84|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|476||||476|42.84|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BCBS UTHCT [115568]|476||||476|223.72|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|476||||476|64.51|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|476||||476|238|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|476||||476|299.88|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|476||||476|35.99|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|476||||476|42.84|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|CIGNA [1260]|CIGNA GWH [126023]|476||||476|49.85|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|476||||476|328.44|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|476||||476|53.55|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|476||||476|42.84|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|476||||476|58.61|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|476||||476|35.99|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|476||||476|42.84|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|476||||476|58.61|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|476||||476|35.99|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|476||||476|35.99|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|476||||476|328.44|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|476||||476|35.99|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|Self-pay|Self-pay|476||||476|166.6|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|476||||476|35.99|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|476||||476|35.99|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|476||||476|59.85|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|476||||476|42.84|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|476||||476|42.84|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|476||||476|59.85|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|476||||476|42.84|328.44|35.99
30687497|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID CMV QN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|476||||476|85.68|328.44|35.99
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|AARP [1000]|AARP [100000]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|AETNA [1015]|AETNA [101529]|274||||274|48|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|BCBS [1155]|BCBS UTHCT [115568]|274||||274|128.78|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|274||||274|52.86|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|274||||274|137|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|274||||274|172.62|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|CIGNA [1260]|CIGNA GWH [126023]|274||||274|40.8|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|274||||274|189.06|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|274||||274|43.86|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|274||||274|48|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|274||||274|48|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|274||||274|189.06|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|Self-pay|Self-pay|274||||274|95.9|189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|274||||274||189.06|40.8
30687498|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC ENTEROVIRUS BY PCR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|274||||274||189.06|40.8
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AARP [1000]|AARP [100000]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AETNA [1015]|AETNA [101529]|315||||315|131.06|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BCBS UTHCT [115568]|315||||315|148.05|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|315||||315|128.17|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|315||||315|157.5|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|315||||315|198.45|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|CIGNA [1260]|CIGNA GWH [126023]|315||||315|173.25|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|315||||315|217.35|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|315||||315|119.75|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|315||||315|131.06|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|315||||315|131.06|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|315||||315|217.35|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|Self-pay|Self-pay|315||||315|110.25|217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|315||||315||217.35|110.25
30687502|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INFLUENZA DNA AMP PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|315||||315||217.35|110.25
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AARP [1000]|AARP [100000]|321||||321|59.85|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|321||||321|43.27|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AETNA [1015]|AETNA [101529]|321||||321|58.61|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|321||||321|35.99|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|321||||321|42.84|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|321||||321|42.84|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS [1155]|BCBS UTHCT [115568]|321||||321|150.87|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|321||||321|64.51|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|321||||321|160.5|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|321||||321|202.23|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|321||||321|35.99|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|321||||321|42.84|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|CIGNA [1260]|CIGNA GWH [126023]|321||||321|49.85|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|GROUP PENSION ADMIN [1450]|GPA [145000]|321||||321|221.49|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|321||||321|53.55|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|321||||321|42.84|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|321||||321|58.61|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|321||||321|35.99|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|321||||321|42.84|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|321||||321|58.61|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|321||||321|35.99|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|321||||321|35.99|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|PHCS [1780]|PHCS MULTIPLAN [178000]|321||||321|221.49|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|321||||321|35.99|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|Self-pay|Self-pay|321||||321|112.35|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|321||||321|35.99|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|321||||321|35.99|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|321||||321|59.85|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|321||||321|42.84|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|321||||321|42.84|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|321||||321|59.85|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|321||||321|42.84|221.49|35.99
30687517|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID QN HEP B|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|321||||321|85.68|221.49|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AARP [1000]|AARP [100000]|386||||386|59.85|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386||||386|43.27|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AETNA [1015]|AETNA [101529]|386||||386|58.61|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386||||386|35.99|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386||||386|42.84|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386||||386|42.84|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BCBS UTHCT [115568]|386||||386|181.42|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386||||386|64.51|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386||||386|193|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386||||386|243.18|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386||||386|35.99|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386||||386|42.84|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|CIGNA [1260]|CIGNA GWH [126023]|386||||386|49.85|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386||||386|266.34|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|386||||386|53.55|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386||||386|42.84|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386||||386|58.61|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386||||386|35.99|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386||||386|42.84|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386||||386|58.61|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386||||386|35.99|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|386||||386|35.99|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386||||386|266.34|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386||||386|35.99|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|Self-pay|Self-pay|386||||386|135.1|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|386||||386|35.99|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386||||386|35.99|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386||||386|59.85|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|386||||386|42.84|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|386||||386|42.84|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386||||386|59.85|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386||||386|42.84|266.34|35.99
30687522|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HEP C|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386||||386|85.68|266.34|35.99
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AARP [1000]|AARP [100000]|319||||319|49.04|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|319||||319|35.44|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AETNA [1015]|AETNA [101529]|319||||319|48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|319||||319|29.48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|319||||319|35.09|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|319||||319|35.09|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BCBS UTHCT [115568]|319||||319|149.93|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|319||||319|52.86|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|319||||319|159.5|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|319||||319|200.97|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|319||||319|29.48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|319||||319|35.09|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|CIGNA [1260]|CIGNA GWH [126023]|319||||319|40.8|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|319||||319|220.11|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|319||||319|43.86|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|319||||319|35.09|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|319||||319|48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|319||||319|29.48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|319||||319|35.09|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|319||||319|48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|319||||319|29.48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|319||||319|29.48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|319||||319|220.11|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|319||||319|29.48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|Self-pay|Self-pay|319||||319|111.65|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|319||||319|29.48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|319||||319|29.48|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|319||||319|49.04|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|319||||319|35.09|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|319||||319|35.09|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|319||||319|49.04|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|319||||319|35.09|220.11|29.48
30687529|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HERPES SIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|319||||319|70.18|220.11|29.48
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|AARP [1000]|AARP [100000]|255||||255|58.33|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|255||||255|42.18|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|AETNA [1015]|AETNA [101529]|255||||255|57.12|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|255||||255|35.08|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|255||||255|41.76|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|255||||255|41.76|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|BCBS [1155]|BCBS UTHCT [115568]|255||||255|119.85|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|255||||255|62.89|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|255||||255|127.5|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|255||||255|160.65|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|255||||255|35.08|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|255||||255|41.76|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|CIGNA [1260]|CIGNA GWH [126023]|255||||255|48.44|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|GROUP PENSION ADMIN [1450]|GPA [145000]|255||||255|175.95|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|255||||255|52.2|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|255||||255|41.76|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|255||||255|57.12|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|255||||255|35.08|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|255||||255|41.76|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|255||||255|57.12|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|255||||255|35.08|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|255||||255|35.08|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|PHCS [1780]|PHCS MULTIPLAN [178000]|255||||255|175.95|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|255||||255|35.08|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|Self-pay|Self-pay|255||||255|89.25|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|255||||255|35.08|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|255||||255|35.08|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|255||||255|58.33|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|255||||255|41.76|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|255||||255|41.76|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|255||||255|58.33|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|255||||255|41.76|175.95|35.08
30687533|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE QN HERPES 6|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|255||||255|83.52|175.95|35.08
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|AARP [1000]|AARP [100000]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|AETNA [1015]|AETNA [101529]|268||||268|48|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|BCBS [1155]|BCBS UTHCT [115568]|268||||268|125.96|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|268||||268|52.86|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|268||||268|134|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|268||||268|168.84|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|CIGNA [1260]|CIGNA GWH [126023]|268||||268|40.8|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|GROUP PENSION ADMIN [1450]|GPA [145000]|268||||268|184.92|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|268||||268|43.86|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|268||||268|48|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|268||||268|48|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|PHCS [1780]|PHCS MULTIPLAN [178000]|268||||268|184.92|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|Self-pay|Self-pay|268||||268|93.8|184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|268||||268||184.92|40.8
30687535|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP HIV-1|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|268||||268||184.92|40.8
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|AARP [1000]|AARP [100000]|543||||543|118.89|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|543||||543|85.95|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|AETNA [1015]|AETNA [101529]|543||||543|116.42|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|543||||543|71.48|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|543||||543|85.1|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|543||||543|85.1|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|BCBS [1155]|BCBS UTHCT [115568]|543||||543|255.21|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|543||||543|128.17|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|543||||543|271.5|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|543||||543|342.09|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|543||||543|71.48|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|543||||543|85.1|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|CIGNA [1260]|CIGNA GWH [126023]|543||||543|98.87|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|543||||543|374.67|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|543||||543|106.38|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|543||||543|85.1|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|543||||543|116.42|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|543||||543|71.48|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|543||||543|85.1|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|543||||543|116.42|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|543||||543|71.48|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|543||||543|71.48|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|543||||543|374.67|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|543||||543|71.48|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|Self-pay|Self-pay|543||||543|190.05|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|543||||543|71.48|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|543||||543|71.48|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|543||||543|118.89|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|543||||543|85.1|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|543||||543|85.1|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|543||||543|118.89|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|543||||543|85.1|374.67|71.48
30687536|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA DETECT NUC ACID HIV-1 QUANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|543||||543|170.2|374.67|71.48
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AARP [1000]|AARP [100000]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AETNA [1015]|AETNA [101529]|730||||730|57.02|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS [1155]|BCBS UTHCT [115568]|730||||730|343.1|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|730||||730|52.86|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|730||||730|365|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|730||||730|459.9|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|CIGNA [1260]|CIGNA GWH [126023]|730||||730|40.8|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|730||||730|503.7|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|730||||730|52.1|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|730||||730|57.02|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|730||||730|57.02|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|730||||730|503.7|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|Self-pay|Self-pay|730||||730|255.5|503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|730||||730||503.7|40.8
30687556|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC MYCOBACTERIUM TUBERCU DNA PCR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|730||||730||503.7|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AARP [1000]|AARP [100000]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AETNA [1015]|AETNA [101529]|512||||512|48|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS [1155]|BCBS UTHCT [115568]|512||||512|240.64|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|512||||512|52.86|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|512||||512|256|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|512||||512|322.56|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|CIGNA [1260]|CIGNA GWH [126023]|512||||512|40.8|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|GROUP PENSION ADMIN [1450]|GPA [145000]|512||||512|353.28|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|512||||512|43.86|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|512||||512|48|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|512||||512|48|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|PHCS [1780]|PHCS MULTIPLAN [178000]|512||||512|353.28|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|Self-pay|Self-pay|512||||512|179.2|353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|512||||512||353.28|40.8
30687581|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP MYCOPLAS P|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|512||||512||353.28|40.8
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AARP [1000]|AARP [100000]|251||||251|49.04|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|251||||251|35.44|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AETNA [1015]|AETNA [101529]|251||||251|48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|251||||251|29.48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|251||||251|35.09|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|251||||251|35.09|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS [1155]|BCBS UTHCT [115568]|251||||251|117.97|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|251||||251|52.86|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|251||||251|125.5|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|251||||251|158.13|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|251||||251|29.48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|251||||251|35.09|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|CIGNA [1260]|CIGNA GWH [126023]|251||||251|40.8|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|251||||251|173.19|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|251||||251|43.86|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|251||||251|35.09|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|251||||251|48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|251||||251|29.48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|251||||251|35.09|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|251||||251|48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|251||||251|29.48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|251||||251|29.48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|251||||251|173.19|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|251||||251|29.48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|Self-pay|Self-pay|251||||251|87.85|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|251||||251|29.48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|251||||251|29.48|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|251||||251|49.04|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|251||||251|35.09|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|251||||251|35.09|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|251||||251|49.04|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|251||||251|35.09|173.19|29.48
30687591|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP GC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|251||||251|70.18|173.19|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|AARP [1000]|AARP [100000]|182||||182|47.76|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182||||182|35.44|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|AETNA [1015]|AETNA [101529]|182||||182|48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182||||182|29.48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182||||182|35.09|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182||||182|35.09|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|BCBS [1155]|BCBS UTHCT [115568]|182||||182|85.54|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182||||182|52.86|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182||||182|91|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182||||182|114.66|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182||||182|29.48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182||||182|35.09|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|CIGNA [1260]|CIGNA GWH [126023]|182||||182|100.1|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182||||182|125.58|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|182||||182|43.86|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182||||182|35.09|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182||||182|48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182||||182|29.48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182||||182|35.09|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182||||182|48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182||||182|29.48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|182||||182|29.48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182||||182|125.58|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182||||182|29.48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|Self-pay|Self-pay|182||||182|63.7|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|182||||182|29.48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182||||182|29.48|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182||||182|47.76|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|182||||182|35.09|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|182||||182|35.09|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182||||182|47.76|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182||||182|35.09|125.58|29.48
30687624|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID HPV HIGH-RISK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182||||182|70.18|125.58|29.48
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|AARP [1000]|AARP [100000]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|AETNA [1015]|AETNA [101529]|498||||498|195.12|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|BCBS [1155]|BCBS UTHCT [115568]|498||||498|234.06|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|498||||498|193.22|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|498||||498|249|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|498||||498|313.74|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|CIGNA [1260]|CIGNA GWH [126023]|498||||498|273.9|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|498||||498|343.62|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|498||||498|178.29|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|498||||498|195.12|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|498||||498|195.12|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|498||||498|343.62|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|Self-pay|Self-pay|498||||498|174.3|343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|498||||498||343.62|174.3
30687631|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID RESP VIRUS 3-5 TARGETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|498||||498||343.62|174.3
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|AARP [1000]|AARP [100000]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|AETNA [1015]|AETNA [101529]|655||||655|298.3|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|BCBS [1155]|BCBS UTHCT [115568]|655||||655|307.85|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|655||||655|321.46|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|655||||655|327.5|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|655||||655|412.65|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|CIGNA [1260]|CIGNA GWH [126023]|655||||655|360.25|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|655||||655|451.95|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|655||||655|272.58|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|655||||655|298.3|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|655||||655|298.3|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|655||||655|451.95|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|Self-pay|Self-pay|655||||655|229.25|451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|655||||655||451.95|229.25
30687632|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC RESP VIRUS 6-11 TARGETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|655||||655||451.95|229.25
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|AARP [1000]|AARP [100000]|428||||428|214|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|428||||428|144.06|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|AETNA [1015]|AETNA [101529]|428||||428|342.31|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|BCBS [1155]|BCBS UTHCT [115568]|428||||428|201.16|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|428||||428|174.01|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|428||||428|214|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|428||||428|269.64|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|CIGNA [1260]|CIGNA GWH [126023]|428||||428|235.4|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|428||||428|295.32|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|428||||428|214|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|428||||428|342.31|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|428||||428|342.31|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|428||||428|295.32|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|Self-pay|Self-pay|428||||428|149.8|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|428||||428|214|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|428||||428|214|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|428||||428|142.63|342.31|142.63
30687637|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IADNA SARSCOV2 & INF A&B & RSV MULT AMP PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|428||||428|285.26|342.31|142.63
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|AARP [1000]|AARP [100000]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|AETNA [1015]|AETNA [101529]|116||||116|48|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|52.86|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|40.8|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|43.86|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|48|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|48|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|Self-pay|Self-pay|116||||116|40.6|80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116||80.04|40.6
30687640|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID STAPH AUREUS AMP PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116||80.04|40.6
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|AARP [1000]|AARP [100000]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|AETNA [1015]|AETNA [101529]|504||||504|48|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|BCBS [1155]|BCBS UTHCT [115568]|504||||504|236.88|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|504||||504|52.86|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|504||||504|252|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|504||||504|317.52|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|CIGNA [1260]|CIGNA GWH [126023]|504||||504|40.8|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|504||||504|347.76|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|504||||504|43.86|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|504||||504|48|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|504||||504|48|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|504||||504|347.76|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|Self-pay|Self-pay|504||||504|176.4|347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|504||||504||347.76|40.8
30687641|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID MRSA AMP PROBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|504||||504||347.76|40.8
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AARP [1000]|AARP [100000]|130||||130|49.04|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|130||||130|35.44|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AETNA [1015]|AETNA [101529]|130||||130|48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|130||||130|29.48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|130||||130|35.09|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|130||||130|35.09|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BCBS UTHCT [115568]|130||||130|61.1|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|130||||130|52.86|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|130||||130|65|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|130||||130|81.9|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|130||||130|29.48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|130||||130|35.09|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|CIGNA [1260]|CIGNA GWH [126023]|130||||130|40.8|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|GROUP PENSION ADMIN [1450]|GPA [145000]|130||||130|89.7|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|130||||130|43.86|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|130||||130|35.09|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|130||||130|48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|130||||130|29.48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|130||||130|35.09|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|130||||130|48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|130||||130|29.48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|130||||130|29.48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|PHCS [1780]|PHCS MULTIPLAN [178000]|130||||130|89.7|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|130||||130|29.48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|Self-pay|Self-pay|130||||130|45.5|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|130||||130|29.48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|130||||130|29.48|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|130||||130|49.04|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|130||||130|35.09|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|130||||130|35.09|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|130||||130|49.04|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|130||||130|35.09|89.7|29.48
30687651|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP STREP A|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|130||||130|70.18|89.7|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|AARP [1000]|AARP [100000]|115||||115|47.87|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|115||||115|35.44|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|AETNA [1015]|AETNA [101529]|115||||115|48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|115||||115|29.48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|115||||115|35.09|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|115||||115|35.09|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|BCBS [1155]|BCBS UTHCT [115568]|115||||115|54.05|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|115||||115|52.86|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|115||||115|57.5|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|115||||115|72.45|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|115||||115|29.48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|115||||115|35.09|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|CIGNA [1260]|CIGNA GWH [126023]|115||||115|63.25|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|115||||115|79.35|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|115||||115|43.86|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|115||||115|35.09|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|115||||115|48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|115||||115|29.48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|115||||115|35.09|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|115||||115|48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|115||||115|29.48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|115||||115|29.48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|115||||115|79.35|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|115||||115|29.48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|Self-pay|Self-pay|115||||115|40.25|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|115||||115|29.48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|115||||115|29.48|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|115||||115|47.87|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|115||||115|35.09|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|115||||115|35.09|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|115||||115|47.87|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|115||||115|35.09|79.35|29.48
30687661|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC TRICHOMONAS VAGINALIS AMP PRB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|115||||115|70.18|79.35|29.48
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AARP [1000]|AARP [100000]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AETNA [1015]|AETNA [101529]|208||||208|48|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BCBS UTHCT [115568]|208||||208|97.76|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|208||||208|52.86|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|208||||208|104|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|208||||208|131.04|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|CIGNA [1260]|CIGNA GWH [126023]|208||||208|40.8|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|208||||208|143.52|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|208||||208|43.86|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|208||||208|48|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|208||||208|48|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|208||||208|143.52|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|Self-pay|Self-pay|208||||208|72.8|143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|208||||208||143.52|40.8
30687798|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC NUC ACID PROBE AMP INFECTIOUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|208||||208||143.52|40.8
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AARP [1000]|AARP [100000]|129||||129|59.85|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129||||129|43.27|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AETNA [1015]|AETNA [101529]|129||||129|58.61|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129||||129|35.99|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129||||129|42.84|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129||||129|42.84|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BCBS UTHCT [115568]|129||||129|60.63|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129||||129|64.51|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129||||129|64.5|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129||||129|81.27|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129||||129|35.99|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129||||129|42.84|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|CIGNA [1260]|CIGNA GWH [126023]|129||||129|49.85|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|129||||129|89.01|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|129||||129|53.55|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129||||129|42.84|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129||||129|58.61|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129||||129|35.99|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129||||129|42.84|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129||||129|58.61|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129||||129|35.99|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|129||||129|35.99|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|129||||129|89.01|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129||||129|35.99|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|Self-pay|Self-pay|129||||129|45.15|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|129||||129|35.99|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129||||129|35.99|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129||||129|59.85|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|129||||129|42.84|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|129||||129|42.84|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129||||129|59.85|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129||||129|42.84|89.01|35.99
30687799|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID NOS QN EA ORGANISM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129||||129|85.68|89.01|35.99
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|AARP [1000]|AARP [100000]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|AETNA [1015]|AETNA [101529]|494||||494|96.02|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|BCBS [1155]|BCBS UTHCT [115568]|494||||494|232.18|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|494||||494|105.73|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|494||||494|247|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|494||||494|311.22|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|CIGNA [1260]|CIGNA GWH [126023]|494||||494|81.59|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|494||||494|340.86|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|494||||494|87.75|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|494||||494|96.02|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|494||||494|96.02|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|494||||494|340.86|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|Self-pay|Self-pay|494||||494|172.9|340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|494||||494||340.86|81.59
30687801|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IA NUC ACID AMP PROBE MULT ORG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|494||||494||340.86|81.59
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AARP [1000]|AARP [100000]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AETNA [1015]|AETNA [101529]|249||||249|22.63|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BCBS UTHCT [115568]|249||||249|117.03|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|249||||249|20.19|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|249||||249|124.5|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|249||||249|156.87|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|CIGNA [1260]|CIGNA GWH [126023]|249||||249|22.2|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|249||||249|171.81|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|249||||249|20.69|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|249||||249|22.63|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|249||||249|22.63|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|249||||249|171.81|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|Self-pay|Self-pay|249||||249|87.15|171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|249||||249||171.81|20.19
30687804|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGNT BY IA INFLUENZA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|249||||249||171.81|20.19
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AARP [1000]|AARP [100000]|88||||88|16.76|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|88||||88|16.7|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AETNA [1015]|AETNA [101529]|88||||88|22.61|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|88||||88|13.89|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|88||||88|16.53|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|88||||88|16.53|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BCBS UTHCT [115568]|88||||88|41.36|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|88||||88|20.17|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|88||||88|44|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|88||||88|55.44|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|88||||88|13.89|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|88||||88|16.53|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|CIGNA [1260]|CIGNA GWH [126023]|88||||88|22.2|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|GROUP PENSION ADMIN [1450]|GPA [145000]|88||||88|60.72|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|88||||88|20.66|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|88||||88|16.53|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|88||||88|22.61|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|88||||88|13.89|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|88||||88|16.53|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|88||||88|22.61|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|88||||88|13.89|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|88||||88|13.89|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|PHCS [1780]|PHCS MULTIPLAN [178000]|88||||88|60.72|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|88||||88|13.89|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|Self-pay|Self-pay|88||||88|30.8|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|88||||88|13.89|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|88||||88|13.89|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|88||||88|16.76|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|88||||88|16.53|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|88||||88|16.53|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|88||||88|16.76|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|88||||88|16.53|60.72|13.89
30687880|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC IMMUNO OPTICAL STREP SCREEN A|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|88||||88|33.06|60.72|13.89
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AARP [1000]|AARP [100000]|158||||158|16.76|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158||||158|16.23|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AETNA [1015]|AETNA [101529]|158||||158|21.98|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158||||158|13.5|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158||||158|16.07|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158||||158|16.07|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS [1155]|BCBS UTHCT [115568]|158||||158|74.26|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158||||158|19.61|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158||||158|79|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158||||158|99.54|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158||||158|13.5|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158||||158|16.07|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|CIGNA [1260]|CIGNA GWH [126023]|158||||158|13.88|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|158||||158|109.02|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|158||||158|20.09|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158||||158|16.07|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158||||158|21.98|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158||||158|13.5|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158||||158|16.07|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158||||158|21.98|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158||||158|13.5|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|158||||158|13.5|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|158||||158|109.02|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158||||158|13.5|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|Self-pay|Self-pay|158||||158|55.3|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|158||||158|13.5|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158||||158|13.5|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158||||158|16.76|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|158||||158|16.07|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|158||||158|16.07|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158||||158|16.76|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158||||158|16.07|109.02|13.5
30687899|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC INF AGENT AG DETECT IA/OPTC SCREEN NOC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158||||158|32.14|109.02|13.5
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|AARP [1000]|AARP [100000]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|AETNA [1015]|AETNA [101529]|1274.8||||1274.8|178.32|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|BCBS [1155]|BCBS UTHCT [115568]|1274.8||||1274.8|599.16|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1274.8||||1274.8|196.32|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1274.8||||1274.8|637.4|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1274.8||||1274.8|803.12|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|CIGNA [1260]|CIGNA GWH [126023]|1274.8||||1274.8|151.55|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1274.8||||1274.8|879.61|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1274.8||||1274.8|162.94|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1274.8||||1274.8|178.32|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1274.8||||1274.8|178.32|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1274.8||||1274.8|879.61|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|Self-pay|Self-pay|1274.8||||1274.8|446.18|879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1274.8||||1274.8||879.61|151.55
30687900|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE INFECT AGENT DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1274.8||||1274.8||879.61|151.55
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|AARP [1000]|AARP [100000]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|AETNA [1015]|AETNA [101529]|960||||960|352.2|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|BCBS [1155]|BCBS UTHCT [115568]|960||||960|451.2|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|960||||960|387.76|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|960||||960|480|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|960||||960|604.8|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|CIGNA [1260]|CIGNA GWH [126023]|960||||960|299.15|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|960||||960|662.4|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|960||||960|321.81|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|960||||960|352.2|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|960||||960|352.2|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|960||||960|662.4|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|Self-pay|Self-pay|960||||960|336|662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|960||||960||662.4|299.15
30687901|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE DNA/RNA HIV-1 REV TRNSCR&PROTEAS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|960||||960||662.4|299.15
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AARP [1000]|AARP [100000]|1059||||1059|359.69|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1059||||1059|260.02|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AETNA [1015]|AETNA [101529]|1059||||1059|352.2|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1059||||1059|216.26|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1059||||1059|257.45|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1059||||1059|257.45|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS [1155]|BCBS UTHCT [115568]|1059||||1059|497.73|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1059||||1059|387.76|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1059||||1059|529.5|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1059||||1059|667.17|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1059||||1059|216.26|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1059||||1059|257.45|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|CIGNA [1260]|CIGNA GWH [126023]|1059||||1059|299.15|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1059||||1059|730.71|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1059||||1059|321.81|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1059||||1059|257.45|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1059||||1059|352.2|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1059||||1059|216.26|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1059||||1059|257.45|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1059||||1059|352.2|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1059||||1059|216.26|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1059||||1059|216.26|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1059||||1059|730.71|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1059||||1059|216.26|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|Self-pay|Self-pay|1059||||1059|370.65|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1059||||1059|216.26|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1059||||1059|216.26|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1059||||1059|359.69|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1059||||1059|257.45|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1059||||1059|257.45|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1059||||1059|359.69|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1059||||1059|257.45|730.71|216.26
30687902|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC GENOTYPE HEPATITIS C|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1059||||1059|514.9|730.71|216.26
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|AARP [1000]|AARP [100000]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|AETNA [1015]|AETNA [101529]|672||||672|668.5|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|BCBS [1155]|BCBS UTHCT [115568]|672||||672|315.84|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|672||||672|672|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|672||||672|336|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|672||||672|423.36|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|CIGNA [1260]|CIGNA GWH [126023]|672||||672|567.7|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|672||||672|463.68|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|672||||672|610.83|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|672||||672|668.5|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|672||||672|668.5|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|672||||672|463.68|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|Self-pay|Self-pay|672||||672|235.2|672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|672||||672||672|235.2
30687903|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|672||||672||672|235.2
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|AARP [1000]|AARP [100000]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|AETNA [1015]|AETNA [101529]|230||||230|35.66|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|BCBS [1155]|BCBS UTHCT [115568]|230||||230|108.1|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|230||||230|39.26|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|230||||230|115|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|230||||230|144.9|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|CIGNA [1260]|CIGNA GWH [126023]|230||||230|30.31|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|230||||230|158.7|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|230||||230|32.59|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|230||||230|35.66|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|230||||230|35.66|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|230||||230|158.7|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|Self-pay|Self-pay|230||||230|80.5|158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|230||||230||158.7|30.31
30687904|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC PHENOTYPE DNA HIV W/CULT ADDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|230||||230||158.7|30.31
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|AARP [1000]|AARP [100000]|773||||773|353.88|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|773||||773|260.02|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|AETNA [1015]|AETNA [101529]|773||||773|352.2|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|773||||773|216.26|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|773||||773|257.45|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|773||||773|257.45|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|BCBS [1155]|BCBS UTHCT [115568]|773||||773|363.31|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|773||||773|387.76|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|773||||773|386.5|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|773||||773|486.99|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|773||||773|216.26|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|773||||773|257.45|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|CIGNA [1260]|CIGNA GWH [126023]|773||||773|425.15|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|773||||773|533.37|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|773||||773|321.81|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|773||||773|257.45|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|773||||773|352.2|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|773||||773|216.26|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|773||||773|257.45|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|773||||773|352.2|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|773||||773|216.26|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|773||||773|216.26|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|773||||773|533.37|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|773||||773|216.26|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|Self-pay|Self-pay|773||||773|270.55|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|773||||773|216.26|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|773||||773|216.26|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|773||||773|353.88|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|773||||773|257.45|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|773||||773|257.45|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|773||||773|353.88|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|773||||773|257.45|533.37|216.26
30687912|EAP|0306 - LABORATORY-BACTERIOLOGY AND MICROBIOLOGY|HC HEP B VIRUS GENOTYPE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|773||||773|514.9|533.37|216.26
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AARP [1000]|AARP [100000]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AETNA [1015]|AETNA [101529]|10.53||||10.53|4.64|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.53||||10.53|3.12|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BCBS UTHCT [115568]|10.53||||10.53|4.95|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.53||||10.53|5.27|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.53||||10.53|5.27|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.53||||10.53|6.63|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.53||||10.53|3.12|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA GWH [126023]|10.53||||10.53|5.79|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.53||||10.53|7.27|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.53||||10.53|5.27|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.53||||10.53|4.64|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.53||||10.53|3.12|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.53||||10.53|4.64|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.53||||10.53|3.12|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.53||||10.53|3.12|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.53||||10.53|7.27|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.53||||10.53|3.12|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|Self-pay|Self-pay|10.53||||10.53|3.69|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.53||||10.53|3.12|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.53||||10.53|3.12|7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.53||||10.53||7.27|3.12
3071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FERROUS SULFATE 300 MG (60 MG IRON)/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.53||||10.53||7.27|3.12
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AARP [1000]|AARP [100000]|118||||118|4.43|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|118||||118|3.2|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AETNA [1015]|AETNA [101529]|118||||118|4.34|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|118||||118|2.66|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|118||||118|3.17|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|118||||118|3.17|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BCBS UTHCT [115568]|118||||118|55.46|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|118||||118|4.78|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|118||||118|59|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|118||||118|74.34|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|118||||118|2.66|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|118||||118|3.17|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|CIGNA [1260]|CIGNA GWH [126023]|118||||118|5.89|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|118||||118|81.42|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|118||||118|3.96|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|118||||118|3.17|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|118||||118|4.34|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|118||||118|2.66|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|118||||118|3.17|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|118||||118|4.34|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|118||||118|2.66|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|118||||118|2.66|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|118||||118|81.42|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|118||||118|2.66|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|Self-pay|Self-pay|118||||118|41.3|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|118||||118|2.66|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|118||||118|2.66|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|118||||118|4.43|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|118||||118|3.17|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|118||||118|3.17|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|118||||118|4.43|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|118||||118|3.17|81.42|2.66
30781001|EAP|0307 - LABORATORY-UROLOGY|HC URINALYSIS AUTO W/MICRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|118||||118|6.34|81.42|2.66
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AARP [1000]|AARP [100000]|44||||44|3.57|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44||||44|3.51|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AETNA [1015]|AETNA [101529]|44||||44|4.75|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44||||44|2.92|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44||||44|3.48|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44||||44|3.48|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS [1155]|BCBS UTHCT [115568]|44||||44|20.68|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44||||44|4.25|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44||||44|22|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44||||44|27.72|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44||||44|2.92|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44||||44|3.48|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|CIGNA [1260]|CIGNA GWH [126023]|44||||44|4.54|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|44||||44|30.36|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|44||||44|4.35|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44||||44|3.48|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44||||44|4.75|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44||||44|2.92|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44||||44|3.48|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44||||44|4.75|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44||||44|2.92|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|44||||44|2.92|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|44||||44|30.36|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44||||44|2.92|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|Self-pay|Self-pay|44||||44|15.4|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|44||||44|2.92|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44||||44|2.92|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44||||44|3.57|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|44||||44|3.48|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|44||||44|3.48|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44||||44|3.57|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44||||44|3.48|30.36|2.92
30781002|EAP|0307 - LABORATORY-UROLOGY|HC UA NONAUTO W/O MICRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44||||44|6.96|30.36|2.92
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AARP [1000]|AARP [100000]|69||||69|3.14|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69|2.27|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AETNA [1015]|AETNA [101529]|69||||69|3.07|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69|1.89|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69|2.25|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69|2.25|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BCBS UTHCT [115568]|69||||69|32.43|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|3.38|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|34.5|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|43.47|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69|1.89|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69|2.25|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|CIGNA [1260]|CIGNA GWH [126023]|69||||69|4.08|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|69||||69|2.81|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69|2.25|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|3.07|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69|1.89|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69|2.25|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|3.07|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69|1.89|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|69||||69|1.89|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69|1.89|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|Self-pay|Self-pay|69||||69|24.15|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|69||||69|1.89|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69|1.89|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69|3.14|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|69||||69|2.25|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|69||||69|2.25|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69|3.14|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69|2.25|47.61|1.89
30781003|EAP|0307 - LABORATORY-UROLOGY|HC UA AUTO W/O MICRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69||||69|4.5|47.61|1.89
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|AARP [1000]|AARP [100000]|7||||7|3.03|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7||||7|2.19|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|AETNA [1015]|AETNA [101529]|7||||7|2.98|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7||||7|1.82|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7||||7|2.17|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7||||7|2.17|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|BCBS [1155]|BCBS UTHCT [115568]|7||||7|3.29|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7||||7|3.26|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7||||7|3.5|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7||||7|4.41|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7||||7|1.82|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7||||7|2.17|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|CIGNA [1260]|CIGNA GWH [126023]|7||||7|2.54|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7||||7|4.83|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7||||7|2.71|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7||||7|2.17|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7||||7|2.98|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7||||7|1.82|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7||||7|2.17|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7||||7|2.98|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7||||7|1.82|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|7||||7|1.82|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7||||7|4.83|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7||||7|1.82|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|Self-pay|Self-pay|7||||7|2.45|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7||||7|1.82|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7||||7|1.82|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7||||7|3.03|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7||||7|2.17|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7||||7|2.17|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7||||7|3.03|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7||||7|2.17|4.83|1.82
30781005|EAP|0307 - LABORATORY-UROLOGY|HC  UA QL/SQ PROTEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7||||7|4.34|4.83|1.82
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AARP [1000]|AARP [100000]|10||||10|4.24|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10||||10|3.08|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AETNA [1015]|AETNA [101529]|10||||10|4.18|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10||||10|2.56|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10||||10|3.05|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10||||10|3.05|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BCBS UTHCT [115568]|10||||10|4.7|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10||||10|4.59|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10||||10|5|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10||||10|6.3|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10||||10|2.56|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10||||10|3.05|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|CIGNA [1260]|CIGNA GWH [126023]|10||||10|3.4|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|10||||10|6.9|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10||||10|3.81|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10||||10|3.05|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10||||10|4.18|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10||||10|2.56|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10||||10|3.05|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10||||10|4.18|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10||||10|2.56|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|10||||10|2.56|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|10||||10|6.9|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10||||10|2.56|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|Self-pay|Self-pay|10||||10|3.5|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10||||10|2.56|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10||||10|2.56|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10||||10|4.24|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10||||10|3.05|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10||||10|3.05|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10||||10|4.24|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10||||10|3.05|6.9|2.56
30781015|EAP|0307 - LABORATORY-UROLOGY|HC UA MICRO ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10||||10|6.1|6.9|2.56
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AARP [1000]|AARP [100000]|143||||143|8.84|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|143||||143|8.7|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AETNA [1015]|AETNA [101529]|143||||143|11.78|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|143||||143|7.23|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|143||||143|8.61|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|143||||143|8.61|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BCBS UTHCT [115568]|143||||143|67.21|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|143||||143|10.5|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|143||||143|71.5|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|143||||143|90.09|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|143||||143|7.23|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|143||||143|8.61|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|CIGNA [1260]|CIGNA GWH [126023]|143||||143|11.78|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|143||||143|98.67|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|143||||143|10.76|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|143||||143|8.61|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|143||||143|11.78|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|143||||143|7.23|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|143||||143|8.61|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|143||||143|11.78|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|143||||143|7.23|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|143||||143|7.23|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|143||||143|98.67|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|143||||143|7.23|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|Self-pay|Self-pay|143||||143|50.05|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|143||||143|7.23|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|143||||143|7.23|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|143||||143|8.84|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|143||||143|8.61|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|143||||143|8.61|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|143||||143|8.84|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|143||||143|8.61|98.67|7.23
30781025|EAP|0307 - LABORATORY-UROLOGY|HC URINE PREGNANCY VISUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|143||||143|17.22|98.67|7.23
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|AARP [1000]|AARP [100000]|31||||31|4.19|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31|3.68|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|AETNA [1015]|AETNA [101529]|31||||31|4.97|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|3.06|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31|3.64|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31|3.64|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|4.53|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|3.06|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31|3.64|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|CIGNA [1260]|CIGNA GWH [126023]|31||||31|3.4|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|4.55|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31|3.64|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|4.97|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|3.06|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31|3.64|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|4.97|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|3.06|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|3.06|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|3.06|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|Self-pay|Self-pay|31||||31|10.85|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|3.06|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|3.06|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31|4.19|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31|3.64|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31|3.64|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31|4.19|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31|3.64|21.39|3.06
30781050|EAP|0307 - LABORATORY-UROLOGY|HC URINE VOLUME MEASURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31|7.28|21.39|3.06
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|AARP [1000]|AARP [100000]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|AETNA [1015]|AETNA [101529]|42.47||||42.47|18.73|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42.47||||42.47|12.59|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|42.47||||42.47|19.96|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|42.47||||42.47|21.24|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|42.47||||42.47|21.24|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|42.47||||42.47|26.76|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|42.47||||42.47|12.59|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|42.47||||42.47|23.36|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|42.47||||42.47|29.3|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|42.47||||42.47|21.24|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42.47||||42.47|18.73|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42.47||||42.47|12.59|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42.47||||42.47|18.73|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|42.47||||42.47|12.59|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|42.47||||42.47|12.59|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|42.47||||42.47|29.3|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42.47||||42.47|12.59|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|Self-pay|Self-pay|42.47||||42.47|14.86|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|42.47||||42.47|12.59|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|42.47||||42.47|12.59|29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42.47||||42.47||29.3|12.59
30793|ERX|0250 - PHARMACY-GENERAL|HYDROMORPHONE 0.2 MG/ML IN SODIUM CHLORIDE 0.9% INFUSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|42.47||||42.47||29.3|12.59
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AARP [1000]|AARP [100000]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AETNA [1015]|AETNA [101529]|44.64||||44.64|19.69|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.64||||44.64|13.24|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|BCBS [1155]|BCBS UTHCT [115568]|44.64||||44.64|20.98|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.64||||44.64|22.32|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.64||||44.64|22.32|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.64||||44.64|28.12|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.64||||44.64|13.24|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|CIGNA [1260]|CIGNA GWH [126023]|44.64||||44.64|24.55|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|44.64||||44.64|30.8|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|44.64||||44.64|22.32|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.64||||44.64|19.69|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.64||||44.64|13.24|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.64||||44.64|19.69|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.64||||44.64|13.24|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|44.64||||44.64|13.24|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|44.64||||44.64|30.8|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.64||||44.64|13.24|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|Self-pay|Self-pay|44.64||||44.64|15.62|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|44.64||||44.64|13.24|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.64||||44.64|13.24|30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.64||||44.64||30.8|13.24
30807|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.64||||44.64||30.8|13.24
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.34||||4.34|1.91|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.34||||4.34|1.29|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|4.34||||4.34|2.04|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.34||||4.34|2.17|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.34||||4.34|2.17|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.34||||4.34|2.73|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.34||||4.34|1.29|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|4.34||||4.34|2.39|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.34||||4.34|2.99|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.34||||4.34|2.17|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.34||||4.34|1.91|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.34||||4.34|1.29|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.34||||4.34|1.91|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.34||||4.34|1.29|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.34||||4.34|1.29|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.34||||4.34|2.99|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.34||||4.34|1.29|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.34||||4.34|1.52|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.34||||4.34|1.29|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.34||||4.34|1.29|2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.34||||4.34||2.99|1.29
30961|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM ACETATE(PHOSPHATE BINDERS) 667 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.34||||4.34||2.99|1.29
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.29||||1.29|0.57|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.29||||1.29|0.38|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.29||||1.29|0.61|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.29||||1.29|0.65|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.29||||1.29|0.65|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.29||||1.29|0.81|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.29||||1.29|0.38|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.29||||1.29|0.71|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.29||||1.29|0.89|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.29||||1.29|0.65|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.29||||1.29|0.57|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.29||||1.29|0.38|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.29||||1.29|0.57|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.29||||1.29|0.38|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.29||||1.29|0.38|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.29||||1.29|0.89|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.29||||1.29|0.38|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|1.29||||1.29|0.45|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.29||||1.29|0.38|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.29||||1.29|0.38|0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.29||||1.29||0.89|0.38
310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.29||||1.29||0.89|0.38
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|AARP [1000]|AARP [100000]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|AETNA [1015]|AETNA [101529]|75||||75|33.08|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75||||75|22.24|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|BCBS [1155]|BCBS UTHCT [115568]|75||||75|35.25|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75||||75|31.29|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75||||75|37.5|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75||||75|47.25|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75||||75|22.24|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|CIGNA [1260]|CIGNA GWH [126023]|75||||75|41.25|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|75||||75|51.75|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|75||||75|37.5|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75||||75|33.08|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75||||75|22.24|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75||||75|33.08|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75||||75|22.24|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|75||||75|22.24|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|75||||75|51.75|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75||||75|22.24|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|Self-pay|Self-pay|75||||75|26.25|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|75||||75|22.24|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75||||75|22.24|51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75||||75||51.75|22.24
31000001|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MYD88 L265P MUTATION DETECTION PCR QNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75||||75||51.75|22.24
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|AARP [1000]|AARP [100000]|105.19||||105.19|55.08|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|AETNA [1015]|AETNA [101529]|105.19||||105.19|39.17|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105.19||||105.19|31.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|BCBS [1155]|BCBS UTHCT [115568]|105.19||||105.19|49.44|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105.19||||105.19|0|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105.19||||105.19|52.6|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105.19||||105.19|66.27|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105.19||||105.19|31.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|CIGNA [1260]|CIGNA GWH [126023]|105.19||||105.19|57.85|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|105.19||||105.19|72.58|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105.19||||105.19|0.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105.19||||105.19|39.17|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105.19||||105.19|31.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105.19||||105.19|39.17|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105.19||||105.19|31.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|105.19||||105.19|31.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|105.19||||105.19|72.58|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105.19||||105.19|31.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|Self-pay|Self-pay|105.19||||105.19|36.82|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105.19||||105.19|31.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105.19||||105.19|31.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105.19||||105.19|55.08|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105.19||||105.19|55.08|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|17 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105.19||||105.19||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AARP [1000]|AARP [100000]|400.83||||400.83|162|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400.83||||400.83||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AETNA [1015]|AETNA [101529]|400.83||||400.83|115.2|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400.83||||400.83|118.85|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400.83||||400.83||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400.83||||400.83||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS [1155]|BCBS UTHCT [115568]|400.83||||400.83|188.39|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400.83||||400.83|0|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400.83||||400.83|200.42|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400.83||||400.83|252.52|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400.83||||400.83|118.85|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400.83||||400.83||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|CIGNA [1260]|CIGNA GWH [126023]|400.83||||400.83|220.46|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|400.83||||400.83|276.57|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|400.83||||400.83|0.19|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400.83||||400.83||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400.83||||400.83|115.2|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400.83||||400.83|118.85|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400.83||||400.83||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400.83||||400.83|115.2|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400.83||||400.83|118.85|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|400.83||||400.83|118.85|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|400.83||||400.83|276.57|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400.83||||400.83|118.85|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|Self-pay|Self-pay|400.83||||400.83|140.29|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|400.83||||400.83|118.85|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400.83||||400.83|118.85|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400.83||||400.83|162|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|400.83||||400.83||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|400.83||||400.83||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400.83||||400.83|162|276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400.83||||400.83||276.57|0.19
31025|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL 6 MG/ML CONCENTRATE,INTRAVENOUS|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400.83||||400.83||276.57|0.19
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|AARP [1000]|AARP [100000]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|AETNA [1015]|AETNA [101529]|6586||||6586|640.22|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|BCBS [1155]|BCBS UTHCT [115568]|6586||||6586|3095.42|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6586||||6586|570.96|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6586||||6586|3293|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6586||||6586|4149.18|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|CIGNA [1260]|CIGNA GWH [126023]|6586||||6586|3622.3|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6586||||6586|4544.34|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6586||||6586|585|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6586||||6586|640.22|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6586||||6586|640.22|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6586||||6586|4544.34|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|Self-pay|Self-pay|6586||||6586|2305.1|4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6586||||6586||4544.34|570.96
31081163|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRCA1 BRCA2 GENE ANALYSIS FULL SEQUENCE ANLYS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6586||||6586||4544.34|570.96
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|AARP [1000]|AARP [100000]|1570||||1570|329.51|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1570||||1570|303|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|AETNA [1015]|AETNA [101529]|1570||||1570|410.4|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1570||||1570|252|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1570||||1570|300|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1570||||1570|300|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|BCBS [1155]|BCBS UTHCT [115568]|1570||||1570|737.9|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1570||||1570|366|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1570||||1570|785|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1570||||1570|989.1|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1570||||1570|252|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1570||||1570|300|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|CIGNA [1260]|CIGNA GWH [126023]|1570||||1570|863.5|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1570||||1570|1083.3|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1570||||1570|375|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1570||||1570|300|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1570||||1570|410.4|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1570||||1570|252|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1570||||1570|300|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1570||||1570|410.4|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1570||||1570|252|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1570||||1570|252|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1570||||1570|1083.3|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1570||||1570|252|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|Self-pay|Self-pay|1570||||1570|549.5|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1570||||1570|252|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1570||||1570|252|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1570||||1570|329.51|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1570||||1570|300|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1570||||1570|300|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1570||||1570|329.51|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1570||||1570|300|1083.3|252
31081170|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC ABL1 GENE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1570||||1570|600|1083.3|252
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|AARP [1000]|AARP [100000]|681||||681|223.69|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|681||||681|165.6|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|AETNA [1015]|AETNA [101529]|681||||681|224.3|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|681||||681|137.73|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|681||||681|163.96|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|681||||681|163.96|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|BCBS [1155]|BCBS UTHCT [115568]|681||||681|320.07|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|681||||681|246.95|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|681||||681|340.5|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|681||||681|429.03|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|681||||681|137.73|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|681||||681|163.96|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|CIGNA [1260]|CIGNA GWH [126023]|681||||681|374.55|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|681||||681|469.89|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|681||||681|204.95|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|681||||681|163.96|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|681||||681|224.3|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|681||||681|137.73|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|681||||681|163.96|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|681||||681|224.3|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|681||||681|137.73|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|681||||681|137.73|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|681||||681|469.89|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|681||||681|137.73|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|Self-pay|Self-pay|681||||681|238.35|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|681||||681|137.73|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|681||||681|137.73|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|681||||681|223.69|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|681||||681|163.96|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|681||||681|163.96|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|681||||681|223.69|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|681||||681|163.96|469.89|137.73
31081206|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 GENE MAJOR BP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|681||||681|327.92|469.89|137.73
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|AARP [1000]|AARP [100000]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|AETNA [1015]|AETNA [101529]|94||||94|94|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|BCBS [1155]|BCBS UTHCT [115568]|94||||94|44.18|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|94||||94|94|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94||||94|47|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|94||||94|59.22|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|CIGNA [1260]|CIGNA GWH [126023]|94||||94|51.7|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|94||||94|64.86|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|94||||94|268.28|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94||||94|94|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94||||94|94|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|94||||94|64.86|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|Self-pay|Self-pay|94||||94|32.9|268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94||||94||268.28|32.9
31081208|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BCR/ABL1 OTHER BREAKPNT QUAL/QUAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|94||||94||268.28|32.9
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|AARP [1000]|AARP [100000]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|AETNA [1015]|AETNA [101529]|1100||||1100|239.95|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|BCBS [1155]|BCBS UTHCT [115568]|1100||||1100|517|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1100||||1100|213.99|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1100||||1100|550|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1100||||1100|693|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|CIGNA [1260]|CIGNA GWH [126023]|1100||||1100|605|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1100||||1100|759|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1100||||1100|219.25|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1100||||1100|239.95|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1100||||1100|239.95|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1100||||1100|759|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|Self-pay|Self-pay|1100||||1100|385|759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1100||||1100||759|213.99
31081210|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC BRAF GENE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1100||||1100||759|213.99
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|AARP [1000]|AARP [100000]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|AETNA [1015]|AETNA [101529]|580||||580|166.39|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|BCBS [1155]|BCBS UTHCT [115568]|580||||580|272.6|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|580||||580|183.2|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|580||||580|290|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|580||||580|365.4|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|CIGNA [1260]|CIGNA GWH [126023]|580||||580|319|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|580||||580|400.2|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|580||||580|152.04|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|580||||580|166.39|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|580||||580|166.39|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|580||||580|400.2|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|Self-pay|Self-pay|580||||580|203|400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|580||||580||400.2|152.04
31081219|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CALR GENE COMMON VARIANTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|580||||580||400.2|152.04
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|AARP [1000]|AARP [100000]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|AETNA [1015]|AETNA [101529]|1480||||1480|595.18|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|BCBS [1155]|BCBS UTHCT [115568]|1480||||1480|695.6|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1480||||1480|530.79|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1480||||1480|740|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1480||||1480|932.4|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|CIGNA [1260]|CIGNA GWH [126023]|1480||||1480|814|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1480||||1480|1021.2|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1480||||1480|543.84|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1480||||1480|595.18|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1480||||1480|595.18|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1480||||1480|1021.2|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|Self-pay|Self-pay|1480||||1480|518|1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1480||||1480||1021.2|518
31081222|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE DUP/DELET VARIANTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1480||||1480||1021.2|518
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|AARP [1000]|AARP [100000]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|AETNA [1015]|AETNA [101529]|1330||||1330|682.63|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|BCBS [1155]|BCBS UTHCT [115568]|1330||||1330|625.1|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1330||||1330|608.78|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1330||||1330|665|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1330||||1330|837.9|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|CIGNA [1260]|CIGNA GWH [126023]|1330||||1330|731.5|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1330||||1330|917.7|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1330||||1330|623.75|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1330||||1330|682.63|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1330||||1330|682.63|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1330||||1330|917.7|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|Self-pay|Self-pay|1330||||1330|465.5|917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1330||||1330||917.7|465.5
31081223|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE ANALYSIS FULL SEQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1330||||1330||917.7|465.5
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|AARP [1000]|AARP [100000]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|AETNA [1015]|AETNA [101529]|1330||||1330|230.86|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|BCBS [1155]|BCBS UTHCT [115568]|1330||||1330|625.1|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1330||||1330|205.88|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1330||||1330|665|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1330||||1330|837.9|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|CIGNA [1260]|CIGNA GWH [126023]|1330||||1330|731.5|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1330||||1330|917.7|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1330||||1330|210.94|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1330||||1330|230.86|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1330||||1330|230.86|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1330||||1330|917.7|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|Self-pay|Self-pay|1330||||1330|465.5|917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1330||||1330||917.7|205.88
31081224|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC CFTR GENE INTRON 8 POLY-T|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1330||||1330||917.7|205.88
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|AARP [1000]|AARP [100000]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|AETNA [1015]|AETNA [101529]|1985||||1985|444.02|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|BCBS [1155]|BCBS UTHCT [115568]|1985||||1985|932.95|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1985||||1985|395.99|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1985||||1985|992.5|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1985||||1985|1250.55|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|CIGNA [1260]|CIGNA GWH [126023]|1985||||1985|1091.75|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1985||||1985|1369.65|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1985||||1985|405.73|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1985||||1985|444.02|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1985||||1985|444.02|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1985||||1985|1369.65|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|Self-pay|Self-pay|1985||||1985|694.75|1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1985||||1985||1369.65|395.99
31081235|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC EGFR GENE COM VARIANTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1985||||1985||1369.65|395.99
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AARP [1000]|AARP [100000]|450||||450|67.13|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450||||450|66.35|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AETNA [1015]|AETNA [101529]|450||||450|89.86|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450||||450|55.18|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450||||450|65.69|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450||||450|65.69|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BCBS UTHCT [115568]|450||||450|211.5|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450||||450|80.14|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450||||450|225|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450||||450|283.5|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450||||450|55.18|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450||||450|65.69|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|CIGNA [1260]|CIGNA GWH [126023]|450||||450|247.5|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|450||||450|310.5|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|450||||450|82.11|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450||||450|65.69|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450||||450|89.86|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450||||450|55.18|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450||||450|65.69|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450||||450|89.86|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450||||450|55.18|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|450||||450|55.18|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|450||||450|310.5|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450||||450|55.18|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|Self-pay|Self-pay|450||||450|157.5|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|450||||450|55.18|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450||||450|55.18|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450||||450|67.13|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|450||||450|65.69|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|450||||450|65.69|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450||||450|67.13|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450||||450|65.69|310.5|55.18
31081240|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F2 ANALYSIS 20210G>A VARIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450||||450|131.38|310.5|55.18
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AARP [1000]|AARP [100000]|255||||255|83.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|255||||255|74.1|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AETNA [1015]|AETNA [101529]|255||||255|100.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|255||||255|61.63|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|255||||255|73.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|255||||255|73.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BCBS UTHCT [115568]|255||||255|119.85|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|255||||255|92.04|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|255||||255|127.5|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|255||||255|160.65|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|255||||255|61.63|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|255||||255|73.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|CIGNA [1260]|CIGNA GWH [126023]|255||||255|140.25|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|255||||255|175.95|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|255||||255|91.71|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|255||||255|73.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|255||||255|100.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|255||||255|61.63|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|255||||255|73.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|255||||255|100.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|255||||255|61.63|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|255||||255|61.63|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|255||||255|175.95|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|255||||255|61.63|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|Self-pay|Self-pay|255||||255|89.25|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|255||||255|61.63|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|255||||255|61.63|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|255||||255|83.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|255||||255|73.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|255||||255|73.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|255||||255|83.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|255||||255|73.37|175.95|61.63
31081241|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC F5 GENE ANALYSIS LEIDEN VARIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|255||||255|146.74|175.95|61.63
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AARP [1000]|AARP [100000]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AETNA [1015]|AETNA [101529]|242||||242|89.42|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BCBS UTHCT [115568]|242||||242|113.74|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|242||||242|98.44|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|242||||242|121|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|242||||242|152.46|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|CIGNA [1260]|CIGNA GWH [126023]|242||||242|133.1|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|242||||242|166.98|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|242||||242|81.7|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|242||||242|89.42|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|242||||242|89.42|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|242||||242|166.98|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|Self-pay|Self-pay|242||||242|84.7|166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|242||||242||166.98|81.7
31081256|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HFE GENE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|242||||242||166.98|81.7
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|AARP [1000]|AARP [100000]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|AETNA [1015]|AETNA [101529]|790||||790|139.9|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|BCBS [1155]|BCBS UTHCT [115568]|790||||790|371.3|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|790||||790|124.76|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|790||||790|395|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|790||||790|497.7|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|CIGNA [1260]|CIGNA GWH [126023]|790||||790|434.5|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|790||||790|545.1|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|790||||790|127.83|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|790||||790|139.9|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|790||||790|139.9|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|790||||790|545.1|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|Self-pay|Self-pay|790||||790|276.5|545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|790||||790||545.1|124.76
31081257|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS COMMON DELETIONS/VARIAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|790||||790||545.1|124.76
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|AARP [1000]|AARP [100000]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|AETNA [1015]|AETNA [101529]|1800||||1800|820.8|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|BCBS [1155]|BCBS UTHCT [115568]|1800||||1800|846|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1800||||1800|732|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1800||||1800|900|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1800||||1800|1134|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|CIGNA [1260]|CIGNA GWH [126023]|1800||||1800|990|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1800||||1800|1242|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1800||||1800|750|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1800||||1800|820.8|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1800||||1800|820.8|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1800||||1800|1242|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|Self-pay|Self-pay|1800||||1800|630|1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1800||||1800||1242|630
31081259|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS FULL GENE SEQUENCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1800||||1800||1242|630
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|AARP [1000]|AARP [100000]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|AETNA [1015]|AETNA [101529]|552||||552|402.91|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|BCBS [1155]|BCBS UTHCT [115568]|552||||552|259.44|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|552||||552|443.59|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|552||||552|276|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|552||||552|347.76|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|CIGNA [1260]|CIGNA GWH [126023]|552||||552|303.6|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|552||||552|380.88|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|552||||552|368.15|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|552||||552|402.91|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|552||||552|402.91|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|552||||552|380.88|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|Self-pay|Self-pay|552||||552|193.2|443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|552||||552||443.59|193.2
31081263|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC IGH VAR REG SOMATIC MUTATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|552||||552||443.59|193.2
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|AARP [1000]|AARP [100000]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|AETNA [1015]|AETNA [101529]|608||||608|276.89|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|BCBS [1155]|BCBS UTHCT [115568]|608||||608|285.76|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|608||||608|246.93|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|608||||608|304|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|608||||608|383.04|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|CIGNA [1260]|CIGNA GWH [126023]|608||||608|334.4|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|608||||608|419.52|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|608||||608|253|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|608||||608|276.89|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|608||||608|276.89|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|608||||608|419.52|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|Self-pay|Self-pay|608||||608|212.8|419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|608||||608||419.52|212.8
31081269|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HBA1/HBA2 GENE ANALYSIS DUP/DEL VARIANTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|608||||608||419.52|212.8
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AARP [1000]|AARP [100000]|649||||649|125.06|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|649||||649|92.58|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AETNA [1015]|AETNA [101529]|649||||649|125.4|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|649||||649|76.99|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|649||||649|91.66|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|649||||649|91.66|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS [1155]|BCBS UTHCT [115568]|649||||649|305.03|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|649||||649|138.07|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|649||||649|324.5|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|649||||649|408.87|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|649||||649|76.99|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|649||||649|91.66|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|CIGNA [1260]|CIGNA GWH [126023]|649||||649|356.95|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|649||||649|447.81|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|649||||649|114.58|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|649||||649|91.66|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|649||||649|125.4|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|649||||649|76.99|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|649||||649|91.66|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|649||||649|125.4|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|649||||649|76.99|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|649||||649|76.99|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|649||||649|447.81|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|649||||649|76.99|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|Self-pay|Self-pay|649||||649|227.15|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|649||||649|76.99|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|649||||649|76.99|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|649||||649|125.06|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|649||||649|91.66|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|649||||649|91.66|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|649||||649|125.06|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|649||||649|91.66|447.81|76.99
31081270|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 GENE ANAL P VAL617PHE VARIAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|649||||649|183.32|447.81|76.99
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|AARP [1000]|AARP [100000]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|AETNA [1015]|AETNA [101529]|237.38||||237.38|170.83|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|BCBS [1155]|BCBS UTHCT [115568]|237.38||||237.38|111.57|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237.38||||237.38|152.34|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237.38||||237.38|118.69|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237.38||||237.38|149.55|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|CIGNA [1260]|CIGNA GWH [126023]|237.38||||237.38|130.56|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|237.38||||237.38|163.79|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|237.38||||237.38|156.09|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237.38||||237.38|170.83|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237.38||||237.38|170.83|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|237.38||||237.38|163.79|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|Self-pay|Self-pay|237.38||||237.38|83.08|170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237.38||||237.38||170.83|83.08
31081273|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KIT GENE ANALYSIS D816 VARIANT(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237.38||||237.38||170.83|83.08
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|AARP [1000]|AARP [100000]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|AETNA [1015]|AETNA [101529]|2633||||2633|264.36|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|BCBS [1155]|BCBS UTHCT [115568]|2633||||2633|1237.51|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2633||||2633|235.77|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2633||||2633|1316.5|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2633||||2633|1658.79|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|CIGNA [1260]|CIGNA GWH [126023]|2633||||2633|1448.15|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2633||||2633|1816.77|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2633||||2633|241.56|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2633||||2633|264.36|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2633||||2633|264.36|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2633||||2633|1816.77|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|Self-pay|Self-pay|2633||||2633|921.55|1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2633||||2633||1816.77|235.77
31081275|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS MUTATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2633||||2633||1816.77|235.77
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|AARP [1000]|AARP [100000]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|AETNA [1015]|AETNA [101529]|620||||620|253.34|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|620||||620|183.83|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|BCBS [1155]|BCBS UTHCT [115568]|620||||620|291.4|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|620||||620|225.94|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|620||||620|310|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|620||||620|390.6|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|620||||620|183.83|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|CIGNA [1260]|CIGNA GWH [126023]|620||||620|341|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|620||||620|427.8|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|620||||620|231.5|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|620||||620|253.34|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|620||||620|183.83|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|620||||620|253.34|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|620||||620|183.83|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|620||||620|183.83|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|620||||620|427.8|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|620||||620|183.83|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|Self-pay|Self-pay|620||||620|217|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|620||||620|183.83|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|620||||620|183.83|427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|620||||620||427.8|183.83
31081279|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC JAK2 TARGETED SEQUENCE ANALYSIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|620||||620||427.8|183.83
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|AARP [1000]|AARP [100000]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|AETNA [1015]|AETNA [101529]|1306||||1306|476.83|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|BCBS [1155]|BCBS UTHCT [115568]|1306||||1306|613.82|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1306||||1306|436.13|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1306||||1306|653|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1306||||1306|822.78|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|CIGNA [1260]|CIGNA GWH [126023]|1306||||1306|718.3|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1306||||1306|901.14|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1306||||1306|435.7|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1306||||1306|476.83|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1306||||1306|476.83|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1306||||1306|901.14|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|Self-pay|Self-pay|1306||||1306|457.1|901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1306||||1306||901.14|435.7
31081301|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MICROSATELLITE INSTABILITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1306||||1306||901.14|435.7
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|AARP [1000]|AARP [100000]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|AETNA [1015]|AETNA [101529]|586||||586|69.86|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|BCBS [1155]|BCBS UTHCT [115568]|586||||586|275.42|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|586||||586|62.31|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|586||||586|293|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|586||||586|369.18|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|CIGNA [1260]|CIGNA GWH [126023]|586||||586|322.3|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|586||||586|404.34|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|586||||586|63.84|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|586||||586|69.86|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|586||||586|69.86|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|586||||586|404.34|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|Self-pay|Self-pay|586||||586|205.1|404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|586||||586||404.34|62.31
31081331|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SNRPN/UBE3A METHYLATION ANALYSIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|586||||586||404.34|62.31
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|AARP [1000]|AARP [100000]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|AETNA [1015]|AETNA [101529]|287||||287|59.71|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BCBS UTHCT [115568]|287||||287|134.89|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|287||||287|65.75|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|287||||287|143.5|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|287||||287|180.81|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|CIGNA [1260]|CIGNA GWH [126023]|287||||287|157.85|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|287||||287|198.03|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|287||||287|54.56|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|287||||287|59.71|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|287||||287|59.71|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|287||||287|198.03|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|Self-pay|Self-pay|287||||287|100.45|198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|287||||287||198.03|54.56
31081332|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC SERPINA1 GENE ANALYSIS COMMON VARIANTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|287||||287||198.03|54.56
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|AARP [1000]|AARP [100000]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|AETNA [1015]|AETNA [101529]|320||||320|232.42|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|BCBS [1155]|BCBS UTHCT [115568]|320||||320|150.4|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|320||||320|207.28|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|320||||320|160|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|320||||320|201.6|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|CIGNA [1260]|CIGNA GWH [126023]|320||||320|176|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|320||||320|220.8|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|320||||320|212.38|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|320||||320|232.42|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|320||||320|232.42|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|320||||320|220.8|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|Self-pay|Self-pay|320||||320|112|232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|320||||320||232.42|112
31081381|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA I TYPING 1 ALLELE/ALLELE GRP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|320||||320||232.42|112
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|AARP [1000]|AARP [100000]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|AETNA [1015]|AETNA [101529]|594||||594|149.28|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|BCBS [1155]|BCBS UTHCT [115568]|594||||594|279.18|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594||||594|164.37|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594||||594|297|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594||||594|374.22|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|CIGNA [1260]|CIGNA GWH [126023]|594||||594|326.7|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|594||||594|409.86|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|594||||594|136.41|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594||||594|149.28|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594||||594|149.28|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|594||||594|409.86|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|Self-pay|Self-pay|594||||594|207.9|409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594||||594||409.86|136.41
31081383|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC HLA II HIGH RES 1 ALLELE/ALLELE GROUP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594||||594||409.86|136.41
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|AARP [1000]|AARP [100000]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|AETNA [1015]|AETNA [101529]|374||||374|87.5|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|BCBS [1155]|BCBS UTHCT [115568]|374||||374|175.78|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|374||||374|78.03|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|374||||374|187|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|374||||374|235.62|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|CIGNA [1260]|CIGNA GWH [126023]|374||||374|205.7|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|GROUP PENSION ADMIN [1450]|GPA [145000]|374||||374|258.06|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|374||||374|79.95|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|374||||374|87.5|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|374||||374|87.5|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|PHCS [1780]|PHCS MULTIPLAN [178000]|374||||374|258.06|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|Self-pay|Self-pay|374||||374|130.9|258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|374||||374||258.06|78.03
31081400|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 1|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|374||||374||258.06|78.03
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|AARP [1000]|AARP [100000]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|AETNA [1015]|AETNA [101529]|494||||494|187.42|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|BCBS [1155]|BCBS UTHCT [115568]|494||||494|232.18|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|494||||494|167.14|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|494||||494|247|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|494||||494|311.22|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|CIGNA [1260]|CIGNA GWH [126023]|494||||494|271.7|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|GROUP PENSION ADMIN [1450]|GPA [145000]|494||||494|340.86|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|494||||494|171.25|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|494||||494|187.42|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|494||||494|187.42|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|PHCS [1780]|PHCS MULTIPLAN [178000]|494||||494|340.86|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|Self-pay|Self-pay|494||||494|172.9|340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|494||||494||340.86|167.14
31081401|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 2|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|494||||494||340.86|167.14
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|AARP [1000]|AARP [100000]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|AETNA [1015]|AETNA [101529]|790||||790|205.66|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|BCBS [1155]|BCBS UTHCT [115568]|790||||790|371.3|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|790||||790|183.4|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|790||||790|395|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|790||||790|497.7|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|CIGNA [1260]|CIGNA GWH [126023]|790||||790|434.5|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|790||||790|545.1|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|790||||790|187.91|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|790||||790|205.66|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|790||||790|205.66|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|790||||790|545.1|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|Self-pay|Self-pay|790||||790|276.5|545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|790||||790||545.1|183.4
31081402|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|790||||790||545.1|183.4
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|AARP [1000]|AARP [100000]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|AETNA [1015]|AETNA [101529]|2360||||2360|253.34|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|BCBS [1155]|BCBS UTHCT [115568]|2360||||2360|1109.2|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2360||||2360|225.94|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2360||||2360|1180|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2360||||2360|1486.8|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|CIGNA [1260]|CIGNA GWH [126023]|2360||||2360|1298|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2360||||2360|1628.4|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2360||||2360|231.5|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2360||||2360|253.34|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2360||||2360|253.34|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2360||||2360|1628.4|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|Self-pay|Self-pay|2360||||2360|826|1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2360||||2360||1628.4|225.94
31081403|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 4|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2360||||2360||1628.4|225.94
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|AARP [1000]|AARP [100000]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|AETNA [1015]|AETNA [101529]|2460||||2460|375.96|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|BCBS [1155]|BCBS UTHCT [115568]|2460||||2460|1156.2|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2460||||2460|335.29|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2460||||2460|1230|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2460||||2460|1549.8|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|CIGNA [1260]|CIGNA GWH [126023]|2460||||2460|1353|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2460||||2460|1697.4|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2460||||2460|343.54|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2460||||2460|375.96|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2460||||2460|375.96|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2460||||2460|1697.4|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|Self-pay|Self-pay|2460||||2460|861|1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2460||||2460||1697.4|335.29
31081404|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 5|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2460||||2460||1697.4|335.29
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|AARP [1000]|AARP [100000]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|AETNA [1015]|AETNA [101529]|2991||||2991|386.98|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|BCBS [1155]|BCBS UTHCT [115568]|2991||||2991|1405.77|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2991||||2991|345.11|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2991||||2991|1495.5|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2991||||2991|1884.33|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|CIGNA [1260]|CIGNA GWH [126023]|2991||||2991|1645.05|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2991||||2991|2063.79|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2991||||2991|353.6|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2991||||2991|386.98|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2991||||2991|386.98|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2991||||2991|2063.79|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|Self-pay|Self-pay|2991||||2991|1046.85|2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2991||||2991||2063.79|345.11
31081406|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC MOLECULAR PATH PROC LEVEL 7|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2991||||2991||2063.79|345.11
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|AARP [1000]|AARP [100000]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|AETNA [1015]|AETNA [101529]|2244||||2244|2244|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|BCBS [1155]|BCBS UTHCT [115568]|2244||||2244|1054.68|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2244||||2244|4.66|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2244||||2244|1122|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2244||||2244|1413.72|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|CIGNA [1260]|CIGNA GWH [126023]|2244||||2244|1234.2|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2244||||2244|1548.36|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2244||||2244|3649.5|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2244||||2244|2244|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2244||||2244|2244|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2244||||2244|1548.36|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|Self-pay|Self-pay|2244||||2244|785.4|3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2244||||2244||3649.5|4.66
31081455|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC GEN SEQ ANALYS SOL ORG/HEMTOLMPHOID NEO 51+GEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2244||||2244||3649.5|4.66
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|AARP [1000]|AARP [100000]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|AETNA [1015]|AETNA [101529]|696||||696|306.94|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|696||||696|206.36|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|BCBS [1155]|BCBS UTHCT [115568]|696||||696|327.12|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|696||||696|31.29|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|696||||696|348|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|696||||696|438.48|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|696||||696|206.36|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|CIGNA [1260]|CIGNA GWH [126023]|696||||696|382.8|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|696||||696|480.24|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|696||||696|348|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|696||||696|306.94|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|696||||696|206.36|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|696||||696|306.94|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|696||||696|206.36|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|696||||696|206.36|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|696||||696|480.24|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|696||||696|206.36|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|Self-pay|Self-pay|696||||696|243.6|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|696||||696|206.36|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|696||||696|206.36|480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|696||||696||480.24|31.29
31081479|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC UNLISTED-MOLECULAR PATH PROC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|696||||696||480.24|31.29
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.28||||2.28|1.01|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.28||||2.28|0.68|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.28||||2.28|1.07|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.28||||2.28|1.14|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.28||||2.28|1.14|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.28||||2.28|1.44|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.28||||2.28|0.68|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.28||||2.28|1.25|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.28||||2.28|1.57|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.28||||2.28|1.14|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.28||||2.28|1.01|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.28||||2.28|0.68|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.28||||2.28|1.01|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.28||||2.28|0.68|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.28||||2.28|0.68|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.28||||2.28|1.57|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.28||||2.28|0.68|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|Self-pay|Self-pay|2.28||||2.28|0.8|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.28||||2.28|0.68|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.28||||2.28|0.68|1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.28||||2.28||1.57|0.68
311|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.28||||2.28||1.57|0.68
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|AARP [1000]|AARP [100000]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|AETNA [1015]|AETNA [101529]|57||||57|27.72|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57||||57|16.9|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|BCBS [1155]|BCBS UTHCT [115568]|57||||57|26.79|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|57||||57|30.51|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57||||57|28.5|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|57||||57|35.91|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|57||||57|16.9|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|CIGNA [1260]|CIGNA GWH [126023]|57||||57|31.35|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|57||||57|39.33|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|57||||57|25.33|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57||||57|27.72|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57||||57|16.9|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57||||57|27.72|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57||||57|16.9|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|57||||57|16.9|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|57||||57|39.33|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57||||57|16.9|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|Self-pay|Self-pay|57||||57|19.95|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|57||||57|16.9|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|57||||57|16.9|39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57||||57||39.33|16.9
31100123|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC SCREEN CERV/VAG THIN LAYER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|57||||57||39.33|16.9
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|AARP [1000]|AARP [100000]|101||||101|16.12|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|101||||101|11.65|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|AETNA [1015]|AETNA [101529]|101||||101|15.77|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|101||||101|9.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|101||||101|11.53|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|101||||101|11.53|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BCBS UTHCT [115568]|101||||101|47.47|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|101||||101|17.37|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|101||||101|50.5|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|101||||101|63.63|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|101||||101|9.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|101||||101|11.53|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|CIGNA [1260]|CIGNA GWH [126023]|101||||101|13.32|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|101||||101|69.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|101||||101|14.41|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|101||||101|11.53|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|101||||101|15.77|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|101||||101|9.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|101||||101|11.53|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|101||||101|15.77|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|101||||101|9.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|101||||101|9.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|101||||101|69.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|101||||101|9.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|Self-pay|Self-pay|101||||101|35.35|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|101||||101|9.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|101||||101|9.69|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|101||||101|16.12|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|101||||101|11.53|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|101||||101|11.53|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|101||||101|16.12|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|101||||101|11.53|69.69|9.69
31183516|EAP|0301 - LABORATORY-CHEMISTRY|HC REF IMMUNO QL SQN MULTIPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|101||||101|23.06|69.69|9.69
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|AARP [1000]|AARP [100000]|833||||833|18.09|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|833||||833|17.44|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|AETNA [1015]|AETNA [101529]|833||||833|23.62|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|833||||833|14.51|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|833||||833|17.27|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|833||||833|17.27|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|BCBS [1155]|BCBS UTHCT [115568]|833||||833|391.51|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|833||||833|21.07|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|833||||833|416.5|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|833||||833|524.79|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|833||||833|14.51|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|833||||833|17.27|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|CIGNA [1260]|CIGNA GWH [126023]|833||||833|15.02|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|833||||833|574.77|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|833||||833|21.59|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|833||||833|17.27|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|833||||833|23.62|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|833||||833|14.51|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|833||||833|17.27|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|833||||833|23.62|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|833||||833|14.51|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|833||||833|14.51|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|833||||833|574.77|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|833||||833|14.51|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|Self-pay|Self-pay|833||||833|291.55|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|833||||833|14.51|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|833||||833|14.51|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|833||||833|18.09|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|833||||833|17.27|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|833||||833|17.27|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|833||||833|18.09|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|833||||833|17.27|574.77|14.51
31183520|EAP|0301 - LABORATORY-CHEMISTRY|HC REG IMMUNOASSAY QN NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|833||||833|34.54|574.77|14.51
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AARP [1000]|AARP [100000]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AETNA [1015]|AETNA [101529]|265||||265|96.77|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|265||||265|78.57|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BCBS UTHCT [115568]|265||||265|124.55|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|265||||265|38.8|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|265||||265|132.5|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|265||||265|166.95|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|265||||265|78.57|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|CIGNA [1260]|CIGNA GWH [126023]|265||||265|43.63|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|265||||265|182.85|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|265||||265|42.3|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|265||||265|96.77|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|265||||265|78.57|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|265||||265|96.77|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|265||||265|78.57|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|265||||265|78.57|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|265||||265|182.85|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|265||||265|78.57|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|Self-pay|Self-pay|265||||265|92.75|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|265||||265|78.57|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|265||||265|78.57|182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|265||||265||182.85|38.8
31188104|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH BODY FLUIDS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|265||||265||182.85|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|AARP [1000]|AARP [100000]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|AETNA [1015]|AETNA [101529]|243||||243|87.72|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|243||||243|72.05|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|BCBS [1155]|BCBS UTHCT [115568]|243||||243|114.21|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|243||||243|38.8|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|243||||243|121.5|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|243||||243|153.09|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|243||||243|72.05|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|CIGNA [1260]|CIGNA GWH [126023]|243||||243|52.7|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|243||||243|167.67|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|243||||243|42.3|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|243||||243|87.72|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|243||||243|72.05|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|243||||243|87.72|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|243||||243|72.05|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|243||||243|72.05|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|243||||243|167.67|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|243||||243|72.05|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|Self-pay|Self-pay|243||||243|85.05|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|243||||243|72.05|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|243||||243|72.05|167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|243||||243||167.67|38.8
31188108|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOPATH CONCENTRATION SMEARS & INTERP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|243||||243||167.67|38.8
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AARP [1000]|AARP [100000]|256||||256|24.67|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|256||||256|45.58|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AETNA [1015]|AETNA [101529]|256||||256|95.26|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|256||||256|75.9|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|256||||256|45.12|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|256||||256|45.12|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BCBS UTHCT [115568]|256||||256|120.32|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|256||||256|54.53|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|256||||256|128|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|256||||256|161.28|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|256||||256|75.9|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|256||||256|45.12|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|CIGNA [1260]|CIGNA GWH [126023]|256||||256|78.68|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|256||||256|176.64|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|256||||256|62.2|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|256||||256|48.33|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|256||||256|95.26|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|256||||256|75.9|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|256||||256|45.12|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|256||||256|95.26|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|256||||256|75.9|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|256||||256|75.9|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|256||||256|176.64|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|256||||256|75.9|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|Self-pay|Self-pay|256||||256|89.6|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|256||||256|75.9|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|256||||256|75.9|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|256||||256|24.67|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|256||||256|45.12|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|256||||256|45.12|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|256||||256|24.67|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|256||||256|45.12|176.64|24.67
31188112|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTO SELCT CELL ENHNCE W/INTP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|256||||256|90.25|176.64|24.67
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|AARP [1000]|AARP [100000]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|AETNA [1015]|AETNA [101529]|60||||60|27.72|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|60||||60|28.2|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60||||60|30.51|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60||||60|30|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60||||60|37.8|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|60||||60|23.52|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|60||||60|41.4|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|60||||60|25.33|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60||||60|27.72|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60||||60|27.72|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|60||||60|41.4|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|Self-pay|Self-pay|60||||60|21|41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60||||60||41.4|21
31188142|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTP CERV/VAG AUTO THIN LAYER PREP MNL SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60||||60||41.4|21
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|AARP [1000]|AARP [100000]|347||||347|24.67|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|347||||347|136.61|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|AETNA [1015]|AETNA [101529]|347||||347|79.13|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|347||||347|102.89|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|347||||347|135.26|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|347||||347|135.26|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|BCBS [1155]|BCBS UTHCT [115568]|347||||347|163.09|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|347||||347|157.6|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|347||||347|173.5|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|347||||347|218.61|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|347||||347|102.89|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|347||||347|135.26|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|CIGNA [1260]|CIGNA GWH [126023]|347||||347|37.66|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|347||||347|239.43|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|347||||347|186.45|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|347||||347|144.86|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|347||||347|79.13|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|347||||347|102.89|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|347||||347|135.26|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|347||||347|79.13|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|347||||347|102.89|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|347||||347|102.89|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|347||||347|239.43|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|347||||347|102.89|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|Self-pay|Self-pay|347||||347|121.45|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|347||||347|102.89|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|347||||347|102.89|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|347||||347|24.67|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|347||||347|135.26|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|347||||347|135.26|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|347||||347|24.67|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|347||||347|135.26|270.52|24.67
31188172|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE EVAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|347||||347|270.52|270.52|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|AARP [1000]|AARP [100000]|381||||381|24.67|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|381||||381|45.58|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|AETNA [1015]|AETNA [101529]|381||||381|218.52|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|381||||381|112.97|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|381||||381|45.12|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|381||||381|45.12|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|BCBS [1155]|BCBS UTHCT [115568]|381||||381|179.07|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|381||||381|54.53|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|381||||381|190.5|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|381||||381|240.03|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|381||||381|112.97|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|381||||381|45.12|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|CIGNA [1260]|CIGNA GWH [126023]|381||||381|97.01|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|381||||381|262.89|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|381||||381|62.2|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|381||||381|48.33|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|381||||381|218.52|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|381||||381|112.97|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|381||||381|45.12|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|381||||381|218.52|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|381||||381|112.97|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|381||||381|112.97|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|381||||381|262.89|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|381||||381|112.97|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|Self-pay|Self-pay|381||||381|133.35|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|381||||381|112.97|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|381||||381|112.97|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|381||||381|24.67|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|381||||381|45.12|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|381||||381|45.12|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|381||||381|24.67|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|381||||381|45.12|262.89|24.67
31188173|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FINE NEEDLE ASPIRATE INTERPRE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|381||||381|90.25|262.89|24.67
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|AARP [1000]|AARP [100000]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|AETNA [1015]|AETNA [101529]|50||||50|42.07|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50||||50|14.83|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|BCBS [1155]|BCBS UTHCT [115568]|50||||50|23.5|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50||||50|9.64|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50||||50|25|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50||||50|31.5|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50||||50|14.83|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|CIGNA [1260]|CIGNA GWH [126023]|50||||50|27.5|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|50||||50|34.5|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50||||50|25|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50||||50|42.07|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50||||50|14.83|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50||||50|42.07|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50||||50|14.83|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|50||||50|14.83|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|50||||50|34.5|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50||||50|14.83|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|Self-pay|Self-pay|50||||50|17.5|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50||||50|14.83|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50||||50|14.83|42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50||||50||42.07|9.64
31188177|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FNA SPEC ADEQUACY EA ADD EVAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50||||50||42.07|9.64
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AARP [1000]|AARP [100000]|499||||499|11.78|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|499||||499|266.76|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AETNA [1015]|AETNA [101529]|499||||499|94.82|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|499||||499|147.95|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|499||||499|264.12|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|499||||499|264.12|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS [1155]|BCBS UTHCT [115568]|499||||499|234.53|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|499||||499|262.82|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|499||||499|249.5|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|499||||499|314.37|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|499||||499|147.95|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|499||||499|264.12|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|CIGNA [1260]|CIGNA GWH [126023]|499||||499|54.13|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|499||||499|344.31|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|499||||499|364.08|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|499||||499|282.87|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|499||||499|94.82|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|499||||499|147.95|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|499||||499|264.12|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|499||||499|94.82|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|499||||499|147.95|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|499||||499|147.95|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|499||||499|344.31|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|499||||499|147.95|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|Self-pay|Self-pay|499||||499|174.65|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|499||||499|147.95|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|499||||499|147.95|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|499||||499|11.78|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|499||||499|264.12|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|499||||499|264.12|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|499||||499|11.78|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|499||||499|264.12|528.23|11.78
31188184|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY FIRST MARKER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|499||||499|528.23|528.23|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AARP [1000]|AARP [100000]|3752||||3752|11.78|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3752||||3752||2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AETNA [1015]|AETNA [101529]|3752||||3752|31.22|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3752||||3752|1112.47|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3752||||3752||2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3752||||3752||2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS [1155]|BCBS UTHCT [115568]|3752||||3752|1763.44|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3752||||3752|37.22|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3752||||3752|1876|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3752||||3752|2363.76|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3752||||3752|1112.47|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3752||||3752||2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|CIGNA [1260]|CIGNA GWH [126023]|3752||||3752|30.9|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3752||||3752|2588.88|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3752||||3752|1876|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3752||||3752||2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3752||||3752|31.22|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3752||||3752|1112.47|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3752||||3752||2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3752||||3752|31.22|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3752||||3752|1112.47|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3752||||3752|1112.47|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3752||||3752|2588.88|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3752||||3752|1112.47|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|Self-pay|Self-pay|3752||||3752|1313.2|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3752||||3752|1112.47|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3752||||3752|1112.47|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3752||||3752|11.78|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3752||||3752||2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3752||||3752||2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3752||||3752|11.78|2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3752||||3752||2588.88|11.78
31188185|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC FLOW CYTOMETRY EA ADDL MARKER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3752||||3752||2588.88|11.78
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|AARP [1000]|AARP [100000]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|AETNA [1015]|AETNA [101529]|1238||||1238|159.36|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|BCBS [1155]|BCBS UTHCT [115568]|1238||||1238|581.86|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1238||||1238|175.46|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1238||||1238|619|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1238||||1238|779.94|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|CIGNA [1260]|CIGNA GWH [126023]|1238||||1238|135.41|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1238||||1238|854.22|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1238||||1238|145.61|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1238||||1238|159.36|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1238||||1238|159.36|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1238||||1238|854.22|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|Self-pay|Self-pay|1238||||1238|433.3|854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1238||||1238||854.22|135.41
31188230|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ANALYSIS LYMPHOCYTE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1238||||1238||854.22|135.41
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|AARP [1000]|AARP [100000]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|AETNA [1015]|AETNA [101529]|393||||393|192.53|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|BCBS [1155]|BCBS UTHCT [115568]|393||||393|184.71|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|393||||393|211.96|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|393||||393|196.5|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|393||||393|247.59|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|CIGNA [1260]|CIGNA GWH [126023]|393||||393|163.45|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|393||||393|271.17|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|393||||393|175.91|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|393||||393|192.53|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|393||||393|192.53|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|393||||393|271.17|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|Self-pay|Self-pay|393||||393|137.55|271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|393||||393||271.17|137.55
31188233|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISSUE CULTURE SKIN/SOLID TISSUE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|393||||393||271.17|137.55
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|AARP [1000]|AARP [100000]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|AETNA [1015]|AETNA [101529]|411||||411|205.61|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|BCBS [1155]|BCBS UTHCT [115568]|411||||411|193.17|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|411||||411|221.81|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|411||||411|205.5|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|411||||411|258.93|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|CIGNA [1260]|CIGNA GWH [126023]|411||||411|171.1|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|411||||411|283.59|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|411||||411|187.88|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|411||||411|205.61|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|411||||411|205.61|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|411||||411|283.59|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|Self-pay|Self-pay|411||||411|143.85|283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|411||||411||283.59|143.85
31188235|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CULTURE TISSUE AMNIOTIC FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|411||||411||283.59|143.85
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AARP [1000]|AARP [100000]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AETNA [1015]|AETNA [101529]|808||||808|196.66|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS [1155]|BCBS UTHCT [115568]|808||||808|379.76|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|808||||808|190.23|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|808||||808|404|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|808||||808|509.04|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|CIGNA [1260]|CIGNA GWH [126023]|808||||808|146.74|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|808||||808|557.52|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|808||||808|179.69|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|808||||808|196.66|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|808||||808|196.66|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|808||||808|557.52|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|Self-pay|Self-pay|808||||808|282.8|557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|808||||808||557.52|146.74
31188237|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC TISS CUL NEO DISORDERS BONE MARROW/BLOOD CELLS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|808||||808||557.52|146.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|AARP [1000]|AARP [100000]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|AETNA [1015]|AETNA [101529]|847||||847|171.67|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|847||||847|251.14|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|BCBS [1155]|BCBS UTHCT [115568]|847||||847|398.09|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|847||||847|187.73|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|847||||847|423.5|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|847||||847|533.61|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|847||||847|251.14|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|CIGNA [1260]|CIGNA GWH [126023]|847||||847|144.74|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|847||||847|584.43|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|847||||847|156.86|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|847||||847|171.67|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|847||||847|251.14|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|847||||847|171.67|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|847||||847|251.14|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|847||||847|251.14|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|847||||847|584.43|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|847||||847|251.14|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|Self-pay|Self-pay|847||||847|296.45|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|847||||847|251.14|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|847||||847|251.14|584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|847||||847||584.43|144.74
31188262|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO COUNT 15-20/2 KARYOTYPES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|847||||847||584.43|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|AARP [1000]|AARP [100000]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|AETNA [1015]|AETNA [101529]|760||||760|197.83|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|760||||760|225.34|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|BCBS [1155]|BCBS UTHCT [115568]|760||||760|357.2|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|760||||760|187.73|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|760||||760|380|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|760||||760|478.8|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|760||||760|225.34|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|CIGNA [1260]|CIGNA GWH [126023]|760||||760|144.74|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|760||||760|524.4|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|760||||760|180.76|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|760||||760|197.83|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|760||||760|225.34|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|760||||760|197.83|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|760||||760|225.34|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|760||||760|225.34|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|760||||760|524.4|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|760||||760|225.34|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|Self-pay|Self-pay|760||||760|266|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|760||||760|225.34|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|760||||760|225.34|524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|760||||760||524.4|144.74
31188264|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROM ANALY 20-25 CELLS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|760||||760||524.4|144.74
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|AARP [1000]|AARP [100000]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|AETNA [1015]|AETNA [101529]|433||||433|29.3|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|433||||433|128.38|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|BCBS [1155]|BCBS UTHCT [115568]|433||||433|203.51|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|433||||433|32.26|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|433||||433|216.5|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|433||||433|272.79|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|433||||433|128.38|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|CIGNA [1260]|CIGNA GWH [126023]|433||||433|24.92|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|433||||433|298.77|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|433||||433|26.78|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|433||||433|29.3|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|433||||433|128.38|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|433||||433|29.3|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|433||||433|128.38|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|433||||433|128.38|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|433||||433|298.77|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|433||||433|128.38|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|Self-pay|Self-pay|433||||433|151.55|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|433||||433|128.38|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|433||||433|128.38|298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|433||||433||298.77|24.92
31188271|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTOGEN DNA PROBE FISH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|433||||433||298.77|24.92
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|AARP [1000]|AARP [100000]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|AETNA [1015]|AETNA [101529]|138||||138|47.62|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138||||138|40.92|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|BCBS [1155]|BCBS UTHCT [115568]|138||||138|64.86|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138||||138|48.39|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138||||138|69|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138||||138|86.94|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138||||138|40.92|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|CIGNA [1260]|CIGNA GWH [126023]|138||||138|37.39|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|GROUP PENSION ADMIN [1450]|GPA [145000]|138||||138|95.22|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138||||138|43.51|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138||||138|47.62|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138||||138|40.92|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138||||138|47.62|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138||||138|40.92|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|138||||138|40.92|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|PHCS [1780]|PHCS MULTIPLAN [178000]|138||||138|95.22|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138||||138|40.92|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|Self-pay|Self-pay|138||||138|48.3|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138||||138|40.92|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138||||138|40.92|95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138||||138||95.22|37.39
31188273|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MOLEC CYTO CHROM IN SIT 10-30|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138||||138||95.22|37.39
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|AARP [1000]|AARP [100000]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|AETNA [1015]|AETNA [101529]|433||||433|57.98|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|433||||433|128.38|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|BCBS [1155]|BCBS UTHCT [115568]|433||||433|203.51|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|433||||433|52.44|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|433||||433|216.5|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|433||||433|272.79|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|433||||433|128.38|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|CIGNA [1260]|CIGNA GWH [126023]|433||||433|40.51|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|433||||433|298.77|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|433||||433|52.98|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|433||||433|57.98|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|433||||433|128.38|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|433||||433|57.98|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|433||||433|128.38|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|433||||433|128.38|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|433||||433|298.77|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|433||||433|128.38|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|Self-pay|Self-pay|433||||433|151.55|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|433||||433|128.38|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|433||||433|128.38|298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|433||||433||298.77|40.51
31188274|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC MCG IP SITU 25-99 CELLS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|433||||433||298.77|40.51
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|AARP [1000]|AARP [100000]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|AETNA [1015]|AETNA [101529]|284||||284|70.03|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|284||||284|84.21|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|BCBS [1155]|BCBS UTHCT [115568]|284||||284|133.48|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|284||||284|62.45|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|284||||284|142|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|284||||284|178.92|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|284||||284|84.21|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|CIGNA [1260]|CIGNA GWH [126023]|284||||284|46.74|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|GROUP PENSION ADMIN [1450]|GPA [145000]|284||||284|195.96|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|284||||284|63.99|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|284||||284|70.03|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|284||||284|84.21|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|284||||284|70.03|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|284||||284|84.21|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|284||||284|84.21|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|PHCS [1780]|PHCS MULTIPLAN [178000]|284||||284|195.96|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|284||||284|84.21|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|Self-pay|Self-pay|284||||284|99.4|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|284||||284|84.21|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|284||||284|84.21|195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|284||||284||195.96|46.74
31188275|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CYTOGEN INTERPHASE 100-300|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|284||||284||195.96|46.74
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|AARP [1000]|AARP [100000]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|AETNA [1015]|AETNA [101529]|654||||654|45.79|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|654||||654|193.91|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|BCBS [1155]|BCBS UTHCT [115568]|654||||654|307.38|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|654||||654|40.83|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|654||||654|327|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|654||||654|412.02|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|654||||654|193.91|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|CIGNA [1260]|CIGNA GWH [126023]|654||||654|29.17|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|654||||654|451.26|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|654||||654|41.84|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|654||||654|45.79|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|654||||654|193.91|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|654||||654|45.79|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|654||||654|193.91|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|654||||654|193.91|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|654||||654|451.26|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|654||||654|193.91|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|Self-pay|Self-pay|654||||654|228.9|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|654||||654|193.91|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|654||||654|193.91|451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|654||||654||451.26|29.17
31188280|EAP|0311 - LABORATORY PATHOLOGY-CYTOLOGY|HC CHROMO ADDL KARYO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|654||||654||451.26|29.17
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|AARP [1000]|AARP [100000]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|AETNA [1015]|AETNA [101529]|675||||675|264.36|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|BCBS [1155]|BCBS UTHCT [115568]|675||||675|317.25|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|675||||675|235.77|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|675||||675|337.5|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|675||||675|425.25|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|CIGNA [1260]|CIGNA GWH [126023]|675||||675|371.25|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|675||||675|465.75|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|675||||675|241.56|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|675||||675|264.36|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|675||||675|264.36|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|675||||675|465.75|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|Self-pay|Self-pay|675||||675|236.25|465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|675||||675||465.75|235.77
31281276|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC KRAS GENE ANAL ADDL VARIANT(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|675||||675||465.75|235.77
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|AARP [1000]|AARP [100000]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|AETNA [1015]|AETNA [101529]|975||||975|404.64|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|975||||975|289.09|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|BCBS [1155]|BCBS UTHCT [115568]|975||||975|458.25|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|975||||975|360.86|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|975||||975|487.5|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|975||||975|614.25|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|975||||975|289.09|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|CIGNA [1260]|CIGNA GWH [126023]|975||||975|536.25|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|975||||975|672.75|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|975||||975|369.74|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|975||||975|404.64|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|975||||975|289.09|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|975||||975|404.64|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|975||||975|289.09|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|975||||975|289.09|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|975||||975|672.75|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|975||||975|289.09|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|Self-pay|Self-pay|975||||975|341.25|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|975||||975|289.09|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|975||||975|289.09|672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|975||||975||672.75|289.09
31281311|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC NRAS GENE ANAL EXON 2 AND 3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|975||||975||672.75|289.09
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|AARP [1000]|AARP [100000]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|AETNA [1015]|AETNA [101529]|823||||823|275.66|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|BCBS [1155]|BCBS UTHCT [115568]|823||||823|386.81|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|823||||823|303.49|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|823||||823|411.5|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|823||||823|518.49|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|CIGNA [1260]|CIGNA GWH [126023]|823||||823|452.65|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|823||||823|567.87|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|823||||823|251.88|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|823||||823|275.66|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|823||||823|275.66|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|823||||823|567.87|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|Self-pay|Self-pay|823||||823|288.05|567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|823||||823||567.87|251.88
31281342|EAP|0310 - LABORATORY PATHOLOGY-GENERAL|HC TRG GENE REARRANGEMENT ANAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|823||||823||567.87|251.88
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AARP [1000]|AARP [100000]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AETNA [1015]|AETNA [101529]|72||||72|21.79|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72||||72|21.35|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS [1155]|BCBS UTHCT [115568]|72||||72|33.84|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72||||72|21.31|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72||||72|36|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72||||72|45.36|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72||||72|21.35|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|CIGNA [1260]|CIGNA GWH [126023]|72||||72|16.98|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|72||||72|49.68|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|72||||72|30.84|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72||||72|21.79|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72||||72|21.35|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72||||72|21.79|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72||||72|21.35|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|72||||72|21.35|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|72||||72|49.68|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72||||72|21.35|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|Self-pay|Self-pay|72||||72|25.2|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|72||||72|21.35|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72||||72|21.35|49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72||||72||49.68|16.98
31288300|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS ONLY LEVEL I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72||||72||49.68|16.98
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AARP [1000]|AARP [100000]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AETNA [1015]|AETNA [101529]|149||||149|43.44|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|149||||149|44.18|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS [1155]|BCBS UTHCT [115568]|149||||149|70.03|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|149||||149|38.8|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|149||||149|74.5|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|149||||149|93.87|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|149||||149|44.18|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|CIGNA [1260]|CIGNA GWH [126023]|149||||149|36.79|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|149||||149|102.81|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|149||||149|30.84|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|149||||149|43.44|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|149||||149|44.18|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|149||||149|43.44|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|149||||149|44.18|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|149||||149|44.18|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|149||||149|102.81|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|149||||149|44.18|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|Self-pay|Self-pay|149||||149|52.15|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|149||||149|44.18|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|149||||149|44.18|102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|149||||149||102.81|30.84
31288302|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|149||||149||102.81|30.84
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AARP [1000]|AARP [100000]|336||||336|24.67|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|336||||336|45.58|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AETNA [1015]|AETNA [101529]|336||||336|58.03|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|336||||336|99.62|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|336||||336|45.12|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|336||||336|45.12|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BCBS UTHCT [115568]|336||||336|157.92|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|336||||336|54.53|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|336||||336|168|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|336||||336|211.68|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|336||||336|99.62|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|336||||336|45.12|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|CIGNA [1260]|CIGNA GWH [126023]|336||||336|45.52|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|GROUP PENSION ADMIN [1450]|GPA [145000]|336||||336|231.84|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|336||||336|62.2|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|336||||336|48.33|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|336||||336|58.03|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|336||||336|99.62|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|336||||336|45.12|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|336||||336|58.03|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|336||||336|99.62|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|336||||336|99.62|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|PHCS [1780]|PHCS MULTIPLAN [178000]|336||||336|231.84|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|336||||336|99.62|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|Self-pay|Self-pay|336||||336|117.6|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|336||||336|99.62|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|336||||336|99.62|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|336||||336|24.67|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|336||||336|45.12|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|336||||336|45.12|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|336||||336|24.67|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|336||||336|45.12|231.84|24.67
31288304|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL III|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|336||||336|90.25|231.84|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AARP [1000]|AARP [100000]|396||||396|24.67|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|396||||396|45.58|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AETNA [1015]|AETNA [101529]|396||||396|99.29|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|396||||396|117.41|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|396||||396|45.12|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|396||||396|45.12|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BCBS UTHCT [115568]|396||||396|186.12|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|396||||396|54.53|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|396||||396|198|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|396||||396|249.48|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|396||||396|117.41|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|396||||396|45.12|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|CIGNA [1260]|CIGNA GWH [126023]|396||||396|76.13|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|396||||396|273.24|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|396||||396|62.2|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|396||||396|48.33|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|396||||396|99.29|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|396||||396|117.41|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|396||||396|45.12|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|396||||396|99.29|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|396||||396|117.41|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|396||||396|117.41|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|396||||396|273.24|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|396||||396|117.41|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|Self-pay|Self-pay|396||||396|138.6|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|396||||396|117.41|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|396||||396|117.41|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|396||||396|24.67|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|396||||396|45.12|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|396||||396|45.12|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|396||||396|24.67|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|396||||396|45.12|273.24|24.67
31288305|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL IV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|396||||396|90.25|273.24|24.67
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AARP [1000]|AARP [100000]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AETNA [1015]|AETNA [101529]|597||||597|391.56|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|597||||597|177.01|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BCBS UTHCT [115568]|597||||597|280.59|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|597||||597|262.82|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|597||||597|298.5|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|597||||597|376.11|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|597||||597|177.01|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|CIGNA [1260]|CIGNA GWH [126023]|597||||597|149.64|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|GROUP PENSION ADMIN [1450]|GPA [145000]|597||||597|411.93|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|597||||597|364.08|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|597||||597|391.56|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|597||||597|177.01|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|597||||597|391.56|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|597||||597|177.01|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|597||||597|177.01|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|PHCS [1780]|PHCS MULTIPLAN [178000]|597||||597|411.93|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|597||||597|177.01|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|Self-pay|Self-pay|597||||597|208.95|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|597||||597|177.01|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|597||||597|177.01|411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|597||||597||411.93|149.64
31288307|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL V|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|597||||597||411.93|149.64
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|AARP [1000]|AARP [100000]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|AETNA [1015]|AETNA [101529]|1011||||1011|595.03|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1011||||1011|299.76|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|BCBS [1155]|BCBS UTHCT [115568]|1011||||1011|475.17|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1011||||1011|659.97|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1011||||1011|505.5|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1011||||1011|636.93|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1011||||1011|299.76|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|CIGNA [1260]|CIGNA GWH [126023]|1011||||1011|222.05|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1011||||1011|697.59|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1011||||1011|820.19|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1011||||1011|595.03|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1011||||1011|299.76|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1011||||1011|595.03|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1011||||1011|299.76|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1011||||1011|299.76|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1011||||1011|697.59|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1011||||1011|299.76|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|Self-pay|Self-pay|1011||||1011|353.85|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1011||||1011|299.76|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1011||||1011|299.76|820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1011||||1011||820.19|222.05
31288309|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC GROSS & MICRO LEVEL VI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1011||||1011||820.19|222.05
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AARP [1000]|AARP [100000]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AETNA [1015]|AETNA [101529]|98||||98|30.34|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|98||||98|29.06|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BCBS UTHCT [115568]|98||||98|46.06|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|98||||98|11.38|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|98||||98|49|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|98||||98|61.74|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|98||||98|29.06|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|CIGNA [1260]|CIGNA GWH [126023]|98||||98|12.91|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|98||||98|67.62|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|98||||98|49|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|98||||98|30.34|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|98||||98|29.06|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|98||||98|30.34|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|98||||98|29.06|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|98||||98|29.06|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|98||||98|67.62|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|98||||98|29.06|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|Self-pay|Self-pay|98||||98|34.3|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|98||||98|29.06|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|98||||98|29.06|67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|98||||98||67.62|11.38
31288311|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC DECALCIFICATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|98||||98||67.62|11.38
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AARP [1000]|AARP [100000]|240||||240|11.78|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|240||||240|45.58|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AETNA [1015]|AETNA [101529]|240||||240|149.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|240||||240|71.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|240||||240|45.12|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|240||||240|45.12|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BCBS UTHCT [115568]|240||||240|112.8|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|240||||240|54.53|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|240||||240|120|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|240||||240|151.2|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|240||||240|71.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|240||||240|45.12|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|CIGNA [1260]|CIGNA GWH [126023]|240||||240|67.99|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|240||||240|165.6|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|240||||240|62.2|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|240||||240|48.33|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|240||||240|149.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|240||||240|71.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|240||||240|45.12|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|240||||240|149.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|240||||240|71.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|240||||240|71.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|240||||240|165.6|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|240||||240|71.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|Self-pay|Self-pay|240||||240|84|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|240||||240|71.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|240||||240|71.16|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|240||||240|11.78|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|240||||240|45.12|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|240||||240|45.12|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|240||||240|11.78|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|240||||240|45.12|165.6|11.78
31288312|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|240||||240|90.25|165.6|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AARP [1000]|AARP [100000]|288||||288|11.78|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|288||||288|30.99|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AETNA [1015]|AETNA [101529]|288||||288|107.38|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|288||||288|85.39|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|288||||288|30.69|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|288||||288|30.69|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS [1155]|BCBS UTHCT [115568]|288||||288|135.36|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|288||||288|38.8|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|288||||288|144|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|288||||288|181.44|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|288||||288|85.39|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|288||||288|30.69|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|CIGNA [1260]|CIGNA GWH [126023]|288||||288|51.72|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|288||||288|198.72|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|288||||288|42.3|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|288||||288|32.86|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|288||||288|107.38|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|288||||288|85.39|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|288||||288|30.69|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|288||||288|107.38|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|288||||288|85.39|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|288||||288|85.39|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|288||||288|198.72|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|288||||288|85.39|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|Self-pay|Self-pay|288||||288|100.8|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|288||||288|85.39|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|288||||288|85.39|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|288||||288|11.78|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|288||||288|30.69|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|288||||288|30.69|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|288||||288|11.78|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|288||||288|30.69|198.72|11.78
31288313|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|288||||288|61.37|198.72|11.78
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|AARP [1000]|AARP [100000]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|AETNA [1015]|AETNA [101529]|283||||283|137.06|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|283||||283|83.91|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|BCBS [1155]|BCBS UTHCT [115568]|283||||283|133.01|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|283||||283|77.06|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|283||||283|141.5|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|283||||283|178.29|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|283||||283|83.91|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|CIGNA [1260]|CIGNA GWH [126023]|283||||283|69.19|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|283||||283|195.27|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|283||||283|141.5|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|283||||283|137.06|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|283||||283|83.91|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|283||||283|137.06|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|283||||283|83.91|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|283||||283|83.91|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|283||||283|195.27|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|283||||283|83.91|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|Self-pay|Self-pay|283||||283|99.05|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|283||||283|83.91|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|283||||283|83.91|195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|283||||283||195.27|69.19
31288314|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC SPECIAL STAIN HISTO W/FROZEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|283||||283||195.27|69.19
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|AARP [1000]|AARP [100000]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|AETNA [1015]|AETNA [101529]|269||||269|158.21|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|269||||269|79.76|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|BCBS [1155]|BCBS UTHCT [115568]|269||||269|126.43|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|269||||269|269|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|269||||269|134.5|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|269||||269|169.47|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|269||||269|79.76|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|CIGNA [1260]|CIGNA GWH [126023]|269||||269|108.23|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|GROUP PENSION ADMIN [1450]|GPA [145000]|269||||269|185.61|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|269||||269|820.19|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|269||||269|158.21|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|269||||269|79.76|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|269||||269|158.21|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|269||||269|79.76|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|269||||269|79.76|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|PHCS [1780]|PHCS MULTIPLAN [178000]|269||||269|185.61|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|269||||269|79.76|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|Self-pay|Self-pay|269||||269|94.15|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|269||||269|79.76|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|269||||269|79.76|820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|269||||269||820.19|79.76
31288319|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC HISTOCHEMISTRY STAIN ENZYME|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|269||||269||820.19|79.76
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|AARP [1000]|AARP [100000]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|AETNA [1015]|AETNA [101529]|300||||300|121.1|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|88.95|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|38.8|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|88.95|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|62.57|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|42.3|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|121.1|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|88.95|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|121.1|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|88.95|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|88.95|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|88.95|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|Self-pay|Self-pay|300||||300|105|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|88.95|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|88.95|207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||207|38.8
31288321|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REFERRED SLIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||207|38.8
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AARP [1000]|AARP [100000]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AETNA [1015]|AETNA [101529]|499||||499|163.44|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|499||||499|147.95|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS [1155]|BCBS UTHCT [115568]|499||||499|234.53|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|499||||499|54.53|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|499||||499|249.5|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|499||||499|314.37|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|499||||499|147.95|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|CIGNA [1260]|CIGNA GWH [126023]|499||||499|103.27|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|499||||499|344.31|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|499||||499|62.2|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|499||||499|163.44|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|499||||499|147.95|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|499||||499|163.44|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|499||||499|147.95|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|499||||499|147.95|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|499||||499|344.31|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|499||||499|147.95|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|Self-pay|Self-pay|499||||499|174.65|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|499||||499|147.95|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|499||||499|147.95|344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|499||||499||344.31|54.53
31288323|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH REQUIRING PREP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|499||||499||344.31|54.53
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|AARP [1000]|AARP [100000]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|AETNA [1015]|AETNA [101529]|31||||31|31|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|9.19|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|31|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|9.19|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|CIGNA [1260]|CIGNA GWH [126023]|31||||31|23.71|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|42.3|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|31|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|9.19|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|31|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|9.19|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|9.19|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|9.19|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|Self-pay|Self-pay|31||||31|10.85|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|9.19|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|9.19|42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31||42.3|9.19
31288329|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURGERY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31||42.3|9.19
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AARP [1000]|AARP [100000]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AETNA [1015]|AETNA [101529]|349||||349|139.34|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|349||||349|103.48|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS [1155]|BCBS UTHCT [115568]|349||||349|164.03|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|349||||349|157.6|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|349||||349|174.5|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|349||||349|219.87|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|349||||349|103.48|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|CIGNA [1260]|CIGNA GWH [126023]|349||||349|64.28|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|349||||349|240.81|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|349||||349|186.45|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|349||||349|139.34|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|349||||349|103.48|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|349||||349|139.34|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|349||||349|103.48|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|349||||349|103.48|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|349||||349|240.81|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|349||||349|103.48|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|Self-pay|Self-pay|349||||349|122.15|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|349||||349|103.48|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|349||||349|103.48|240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|349||||349||240.81|64.28
31288331|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CNSLT FROZN SECTION SGL SPCMN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|349||||349||240.81|64.28
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|AARP [1000]|AARP [100000]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|AETNA [1015]|AETNA [101529]|188||||188|77.14|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|188||||188|55.74|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|BCBS [1155]|BCBS UTHCT [115568]|188||||188|88.36|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|188||||188|26.27|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|188||||188|94|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|188||||188|118.44|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|188||||188|55.74|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|CIGNA [1260]|CIGNA GWH [126023]|188||||188|28.88|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|188||||188|129.72|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|188||||188|94|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|188||||188|77.14|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|188||||188|55.74|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|188||||188|77.14|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|188||||188|55.74|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|188||||188|55.74|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|188||||188|129.72|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|188||||188|55.74|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|Self-pay|Self-pay|188||||188|65.8|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|188||||188|55.74|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|188||||188|55.74|129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|188||||188||129.72|26.27
31288332|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC CONSULT PATH SURG EA ADDL FRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|188||||188||129.72|26.27
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|AARP [1000]|AARP [100000]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|AETNA [1015]|AETNA [101529]|323||||323|127.75|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|323||||323|95.77|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|BCBS [1155]|BCBS UTHCT [115568]|323||||323|151.81|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|323||||323|323|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|323||||323|161.5|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|323||||323|203.49|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|323||||323|95.77|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|CIGNA [1260]|CIGNA GWH [126023]|323||||323|65.68|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|GROUP PENSION ADMIN [1450]|GPA [145000]|323||||323|222.87|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|323||||323|820.19|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|323||||323|127.75|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|323||||323|95.77|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|323||||323|127.75|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|323||||323|95.77|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|323||||323|95.77|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|PHCS [1780]|PHCS MULTIPLAN [178000]|323||||323|222.87|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|323||||323|95.77|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|Self-pay|Self-pay|323||||323|113.05|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|323||||323|95.77|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|323||||323|95.77|820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|323||||323||820.19|65.68
31288333|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT 1|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|323||||323||820.19|65.68
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|AARP [1000]|AARP [100000]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|AETNA [1015]|AETNA [101529]|321||||321|80.33|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|321||||321|95.18|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|BCBS [1155]|BCBS UTHCT [115568]|321||||321|150.87|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|321||||321|19.7|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|321||||321|160.5|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|321||||321|202.23|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|321||||321|95.18|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|CIGNA [1260]|CIGNA GWH [126023]|321||||321|38.44|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|321||||321|221.49|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|321||||321|160.5|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|321||||321|80.33|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|321||||321|95.18|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|321||||321|80.33|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|321||||321|95.18|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|321||||321|95.18|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|321||||321|221.49|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|321||||321|95.18|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|Self-pay|Self-pay|321||||321|112.35|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|321||||321|95.18|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|321||||321|95.18|221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|321||||321||221.49|19.7
31288334|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC INTRAOP CYTO PATH CONSULT ADDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|321||||321||221.49|19.7
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AARP [1000]|AARP [100000]|438||||438|45.77|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|438||||438||302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AETNA [1015]|AETNA [101529]|438||||438|131.21|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|438||||438|129.87|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|438||||438||302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|438||||438||302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BCBS UTHCT [115568]|438||||438|205.86|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|438||||438|78.81|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|438||||438|219|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|438||||438|275.94|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|438||||438|129.87|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|438||||438||302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|CIGNA [1260]|CIGNA GWH [126023]|438||||438|240.9|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|438||||438|302.22|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|438||||438|219|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|438||||438||302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|438||||438|131.21|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|438||||438|129.87|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|438||||438||302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|438||||438|131.21|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|438||||438|129.87|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|438||||438|129.87|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|438||||438|302.22|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|438||||438|129.87|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|Self-pay|Self-pay|438||||438|153.3|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|438||||438|129.87|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|438||||438|129.87|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|438||||438|45.77|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|438||||438||302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|438||||438||302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|438||||438|45.77|302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|438||||438||302.22|45.77
31288341|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IHC EACH ADDL STAIN PER SPEC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|438||||438||302.22|45.77
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AARP [1000]|AARP [100000]|561||||561|34.82|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|561||||561|136.61|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AETNA [1015]|AETNA [101529]|561||||561|149.14|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|561||||561|166.34|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|561||||561|135.26|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|561||||561|135.26|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BCBS UTHCT [115568]|561||||561|263.67|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|561||||561|262.82|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|561||||561|280.5|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|561||||561|353.43|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|561||||561|166.34|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|561||||561|135.26|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|CIGNA [1260]|CIGNA GWH [126023]|561||||561|70.94|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|561||||561|387.09|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|561||||561|186.45|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|561||||561|144.86|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|561||||561|149.14|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|561||||561|166.34|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|561||||561|135.26|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|561||||561|149.14|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|561||||561|166.34|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|561||||561|166.34|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|561||||561|387.09|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|561||||561|166.34|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|Self-pay|Self-pay|561||||561|196.35|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|561||||561|166.34|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|561||||561|166.34|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|561||||561|34.82|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|561||||561|135.26|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|561||||561|135.26|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|561||||561|34.82|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|561||||561|135.26|387.09|34.82
31288342|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOCYTOCHEMISTRY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|561||||561|270.52|387.09|34.82
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|AARP [1000]|AARP [100000]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|AETNA [1015]|AETNA [101529]|168||||168|168|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|168||||168|49.81|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|BCBS [1155]|BCBS UTHCT [115568]|168||||168|78.96|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|168||||168|168|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|168||||168|84|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|168||||168|105.84|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|168||||168|49.81|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|CIGNA [1260]|CIGNA GWH [126023]|168||||168|71.8|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|168||||168|115.92|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|168||||168|364.08|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|168||||168|168|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|168||||168|49.81|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|168||||168|168|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|168||||168|49.81|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|168||||168|49.81|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|168||||168|115.92|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|168||||168|49.81|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|Self-pay|Self-pay|168||||168|58.8|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|168||||168|49.81|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|168||||168|49.81|364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|168||||168||364.08|49.81
31288346|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOFLUOR PER SPEC 1ST SINGL AB STAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|168||||168||364.08|49.81
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|AARP [1000]|AARP [100000]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|AETNA [1015]|AETNA [101529]|848||||848|177.31|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|848||||848|251.43|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|BCBS [1155]|BCBS UTHCT [115568]|848||||848|398.56|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|848||||848|262.82|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|848||||848|424|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|848||||848|534.24|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|848||||848|251.43|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|CIGNA [1260]|CIGNA GWH [126023]|848||||848|85.3|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|848||||848|585.12|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|848||||848|186.45|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|848||||848|177.31|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|848||||848|251.43|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|848||||848|177.31|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|848||||848|251.43|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|848||||848|251.43|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|848||||848|585.12|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|848||||848|251.43|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|Self-pay|Self-pay|848||||848|296.8|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|848||||848|251.43|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|848||||848|251.43|585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|848||||848||585.12|85.3
31288360|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC TUMOR IMMUNO HISTOCHEM/MANUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|848||||848||585.12|85.3
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|AARP [1000]|AARP [100000]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|AETNA [1015]|AETNA [101529]|610||||610|179.83|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|610||||610|180.87|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|BCBS [1155]|BCBS UTHCT [115568]|610||||610|286.7|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|610||||610|262.82|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|610||||610|305|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|610||||610|384.3|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|610||||610|180.87|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|CIGNA [1260]|CIGNA GWH [126023]|610||||610|116.23|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|610||||610|420.9|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|610||||610|364.08|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|610||||610|179.83|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|610||||610|180.87|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|610||||610|179.83|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|610||||610|180.87|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|610||||610|180.87|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|610||||610|420.9|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|610||||610|180.87|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|Self-pay|Self-pay|610||||610|213.5|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|610||||610|180.87|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|610||||610|180.87|420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|610||||610||420.9|116.23
31288361|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IMMUNOHISTOCHEM TUMOR QN/SQN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|610||||610||420.9|116.23
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|AARP [1000]|AARP [100000]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|AETNA [1015]|AETNA [101529]|190||||190|190|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|190||||190|56.34|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|BCBS [1155]|BCBS UTHCT [115568]|190||||190|89.3|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|190||||190|119.54|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|190||||190|95|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|190||||190|119.7|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|190||||190|56.34|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|CIGNA [1260]|CIGNA GWH [126023]|190||||190|104.5|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|190||||190|131.1|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|190||||190|95|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|190||||190|190|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|190||||190|56.34|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|190||||190|190|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|190||||190|56.34|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|190||||190|56.34|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|190||||190|131.1|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|190||||190|56.34|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|Self-pay|Self-pay|190||||190|66.5|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|190||||190|56.34|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|190||||190|56.34|190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|190||||190||190|56.34
31288364|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRIDIZATION EA ADDL PROBE STAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|190||||190||190|56.34
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|AARP [1000]|AARP [100000]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|AETNA [1015]|AETNA [101529]|470||||470|256.03|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|470||||470|139.36|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|BCBS [1155]|BCBS UTHCT [115568]|470||||470|220.9|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|470||||470|157.6|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|470||||470|235|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|470||||470|296.1|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|470||||470|139.36|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|CIGNA [1260]|CIGNA GWH [126023]|470||||470|108.14|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|470||||470|324.3|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|470||||470|186.45|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|470||||470|256.03|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|470||||470|139.36|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|470||||470|256.03|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|470||||470|139.36|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|470||||470|139.36|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|470||||470|324.3|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|470||||470|139.36|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|Self-pay|Self-pay|470||||470|164.5|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|470||||470|139.36|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|470||||470|139.36|324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|470||||470||324.3|108.14
31288365|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH PER SPECIMEN 1ST PROBE STAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|470||||470||324.3|108.14
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|AARP [1000]|AARP [100000]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|AETNA [1015]|AETNA [101529]|843||||843|391.94|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|843||||843|249.95|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|BCBS [1155]|BCBS UTHCT [115568]|843||||843|396.21|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|843||||843|262.82|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|843||||843|421.5|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|843||||843|531.09|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|843||||843|249.95|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|CIGNA [1260]|CIGNA GWH [126023]|843||||843|463.65|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|843||||843|581.67|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|843||||843|364.08|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|843||||843|391.94|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|843||||843|249.95|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|843||||843|391.94|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|843||||843|249.95|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|843||||843|249.95|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|843||||843|581.67|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|843||||843|249.95|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|Self-pay|Self-pay|843||||843|295.05|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|843||||843|249.95|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|843||||843|249.95|581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|843||||843||581.67|249.95
31288366|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC IN SITU HYBRD EA MULTI STAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|843||||843||581.67|249.95
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AARP [1000]|AARP [100000]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AETNA [1015]|AETNA [101529]|966||||966|485.5|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|966||||966|286.42|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS [1155]|BCBS UTHCT [115568]|966||||966|454.02|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|966||||966|157.6|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|966||||966|483|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|966||||966|608.58|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|966||||966|286.42|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|CIGNA [1260]|CIGNA GWH [126023]|966||||966|531.3|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|966||||966|666.54|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|966||||966|186.45|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|966||||966|485.5|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|966||||966|286.42|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|966||||966|485.5|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|966||||966|286.42|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|966||||966|286.42|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|966||||966|666.54|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|966||||966|286.42|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|Self-pay|Self-pay|966||||966|338.1|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|966||||966|286.42|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|966||||966|286.42|666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|966||||966||666.54|157.6
31288374|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC M/PHMTRC ANAL ISH COMPUTER EA MULTIPRB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|966||||966||666.54|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|AARP [1000]|AARP [100000]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|AETNA [1015]|AETNA [101529]|830||||830|573.72|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|830||||830|246.1|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|BCBS [1155]|BCBS UTHCT [115568]|830||||830|390.1|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|830||||830|157.6|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|830||||830|415|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|830||||830|522.9|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|830||||830|246.1|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|CIGNA [1260]|CIGNA GWH [126023]|830||||830|456.5|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|830||||830|572.7|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|830||||830|186.45|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|830||||830|573.72|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|830||||830|246.1|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|830||||830|573.72|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|830||||830|246.1|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|830||||830|246.1|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|830||||830|572.7|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|830||||830|246.1|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|Self-pay|Self-pay|830||||830|290.5|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|830||||830|246.1|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|830||||830|246.1|573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|830||||830||573.72|157.6
31288377|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC ISH M/PHMTRC ALYS QN/SEMI-QN EA MULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|830||||830||573.72|157.6
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|AARP [1000]|AARP [100000]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|AETNA [1015]|AETNA [101529]|990||||990|254.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|990||||990|293.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|BCBS [1155]|BCBS UTHCT [115568]|990||||990|465.3|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|990||||990|119.97|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|990||||990|495|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|990||||990|623.7|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|990||||990|293.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|CIGNA [1260]|CIGNA GWH [126023]|990||||990|157.76|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|990||||990|683.1|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|990||||990|495|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|990||||990|254.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|990||||990|293.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|990||||990|254.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|990||||990|293.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|990||||990|293.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|990||||990|683.1|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|990||||990|293.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|Self-pay|Self-pay|990||||990|346.5|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|990||||990|293.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|990||||990|293.54|683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|990||||990||683.1|119.97
31288381|EAP|0312 - LABORATORY PATHOLOGY-HISTOLOGY|HC MICRODISECTION MANUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|990||||990||683.1|119.97
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AARP [1000]|AARP [100000]|474.49||||474.49|177.7|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|474.49||||474.49|177.26|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AETNA [1015]|AETNA [101529]|474.49||||474.49|421.87|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|474.49||||474.49|140.69|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|474.49||||474.49|175.5|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|474.49||||474.49|175.5|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS [1155]|BCBS UTHCT [115568]|474.49||||474.49|223.01|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|474.49||||474.49|0|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|474.49||||474.49|237.25|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|474.49||||474.49|298.93|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|474.49||||474.49|140.69|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|474.49||||474.49|175.5|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|CIGNA [1260]|CIGNA GWH [126023]|474.49||||474.49|260.97|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|474.49||||474.49|327.4|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|474.49||||474.49|109.29|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|474.49||||474.49|175.5|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|474.49||||474.49|421.87|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|474.49||||474.49|140.69|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|474.49||||474.49|175.5|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|474.49||||474.49|421.87|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|474.49||||474.49|140.69|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|474.49||||474.49|140.69|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|474.49||||474.49|327.4|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|474.49||||474.49|140.69|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|Self-pay|Self-pay|474.49||||474.49|166.07|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|474.49||||474.49|140.69|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|474.49||||474.49|140.69|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|474.49||||474.49|177.7|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|474.49||||474.49|175.5|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|474.49||||474.49|175.5|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|474.49||||474.49|177.7|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|474.49||||474.49|175.5|421.87|109.29
31310|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 2 MG INTRA-CATHETER SOLUTION|2 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|474.49||||474.49|351|421.87|109.29
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.67||||0.67|0.3|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.67||||0.67|0.2|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.67||||0.67|0.31|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.67||||0.67|0.34|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.67||||0.67|0.34|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.67||||0.67|0.42|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.67||||0.67|0.2|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.67||||0.67|0.37|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.67||||0.67|0.46|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.67||||0.67|0.34|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.67||||0.67|0.3|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.67||||0.67|0.2|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.67||||0.67|0.3|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.67||||0.67|0.2|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.67||||0.67|0.2|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.67||||0.67|0.46|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.67||||0.67|0.2|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|Self-pay|Self-pay|0.67||||0.67|0.23|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.67||||0.67|0.2|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.67||||0.67|0.2|0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.67||||0.67||0.46|0.2
31336|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE 54 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.67||||0.67||0.46|0.2
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|AARP [1000]|AARP [100000]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|AETNA [1015]|AETNA [101529]|843||||843|341.09|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|843||||843|249.95|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|BCBS [1155]|BCBS UTHCT [115568]|843||||843|396.21|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|843||||843|262.82|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|843||||843|421.5|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|843||||843|531.09|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|843||||843|249.95|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|CIGNA [1260]|CIGNA GWH [126023]|843||||843|463.65|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|843||||843|581.67|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|843||||843|364.08|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|843||||843|341.09|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|843||||843|249.95|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|843||||843|341.09|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|843||||843|249.95|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|843||||843|249.95|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|843||||843|581.67|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|843||||843|249.95|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|Self-pay|Self-pay|843||||843|295.05|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|843||||843|249.95|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|843||||843|249.95|581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|843||||843||581.67|249.95
31400416|EAP|0314 - LABORATORY PATHOLOGY-BIOPSY|HC PATH GROSS & MICRO PROSTATE NDL BX ANY METHOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|843||||843||581.67|249.95
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|AARP [1000]|AARP [100000]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|AETNA [1015]|AETNA [101529]|4.12||||4.12|1.82|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.12||||4.12|1.22|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BCBS UTHCT [115568]|4.12||||4.12|1.94|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.12||||4.12|2.06|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.12||||4.12|2.06|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.12||||4.12|2.6|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.12||||4.12|1.22|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|CIGNA [1260]|CIGNA GWH [126023]|4.12||||4.12|2.27|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.12||||4.12|2.84|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.12||||4.12|2.06|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.12||||4.12|1.82|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.12||||4.12|1.22|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.12||||4.12|1.82|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.12||||4.12|1.22|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.12||||4.12|1.22|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.12||||4.12|2.84|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.12||||4.12|1.22|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|Self-pay|Self-pay|4.12||||4.12|1.44|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.12||||4.12|1.22|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.12||||4.12|1.22|2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.12||||4.12||2.84|1.22
31577|ERX|0250 - PHARMACY-GENERAL|ALBUTEROL SULFATE 0.63 MG/3 ML SOLUTION FOR NEBULIZATION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.12||||4.12||2.84|1.22
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|AARP [1000]|AARP [100000]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|AETNA [1015]|AETNA [101529]|350.89||||350.89|154.74|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|350.89||||350.89|104.04|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|BCBS [1155]|BCBS UTHCT [115568]|350.89||||350.89|164.92|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|350.89||||350.89|175.45|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|350.89||||350.89|175.45|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|350.89||||350.89|221.06|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|350.89||||350.89|104.04|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|CIGNA [1260]|CIGNA GWH [126023]|350.89||||350.89|192.99|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|350.89||||350.89|242.11|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|350.89||||350.89|175.45|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|350.89||||350.89|154.74|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|350.89||||350.89|104.04|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|350.89||||350.89|154.74|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|350.89||||350.89|104.04|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|350.89||||350.89|104.04|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|350.89||||350.89|242.11|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|350.89||||350.89|104.04|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|Self-pay|Self-pay|350.89||||350.89|122.81|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|350.89||||350.89|104.04|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|350.89||||350.89|104.04|242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|350.89||||350.89||242.11|104.04
3189|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOCINONIDE 0.05 % TOPICAL OINTMENT|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|350.89||||350.89||242.11|104.04
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AARP [1000]|AARP [100000]|69.75||||69.75|64.65|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69.75||||69.75||64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|69.75||||69.75|24.84|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69.75||||69.75|20.68|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69.75||||69.75||64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69.75||||69.75||64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|69.75||||69.75|32.78|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69.75||||69.75|0|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69.75||||69.75|34.88|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69.75||||69.75|43.94|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69.75||||69.75|20.68|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69.75||||69.75||64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|69.75||||69.75|38.36|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|69.75||||69.75|48.13|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|69.75||||69.75|1|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69.75||||69.75||64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.75||||69.75|24.84|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69.75||||69.75|20.68|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69.75||||69.75||64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69.75||||69.75|24.84|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69.75||||69.75|20.68|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|69.75||||69.75|20.68|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|69.75||||69.75|48.13|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69.75||||69.75|20.68|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|Self-pay|Self-pay|69.75||||69.75|24.41|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|69.75||||69.75|20.68|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69.75||||69.75|20.68|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69.75||||69.75|64.65|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|69.75||||69.75||64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|69.75||||69.75||64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69.75||||69.75|64.65|64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69.75||||69.75||64.65|1
31921|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ENOXAPARIN 150 MG/ML SUBCUTANEOUS SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69.75||||69.75||64.65|1
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|398.85||||398.85|131.24|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|398.85||||398.85||275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|398.85||||398.85|169.58|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|398.85||||398.85|118.26|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|398.85||||398.85||275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|398.85||||398.85||275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BCBS UTHCT [115568]|398.85||||398.85|187.46|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|398.85||||398.85|0|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|398.85||||398.85|199.43|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|398.85||||398.85|251.28|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|398.85||||398.85|118.26|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|398.85||||398.85||275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA GWH [126023]|398.85||||398.85|219.37|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|398.85||||398.85|275.21|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|398.85||||398.85|199.43|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|398.85||||398.85||275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|398.85||||398.85|169.58|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|398.85||||398.85|118.26|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|398.85||||398.85||275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|398.85||||398.85|169.58|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|398.85||||398.85|118.26|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|398.85||||398.85|118.26|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|398.85||||398.85|275.21|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|398.85||||398.85|118.26|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|398.85||||398.85|139.6|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|398.85||||398.85|118.26|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|398.85||||398.85|118.26|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|398.85||||398.85|131.24|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|398.85||||398.85||275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|398.85||||398.85||275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|398.85||||398.85|131.24|275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|398.85||||398.85||275.21|118.26
31922|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ERTAPENEM 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|398.85||||398.85||275.21|118.26
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AARP [1000]|AARP [100000]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|383||||383|46.01|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|383||||383|35.75|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|383||||383|180.01|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|383||||383|139.64|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|383||||383|191.5|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|383||||383|241.29|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|383||||383|35.75|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|383||||383|54.73|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|383||||383|264.27|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|383||||383|136.21|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|383||||383|46.01|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|383||||383|35.75|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|383||||383|46.01|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|383||||383|35.75|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|383||||383|35.75|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|383||||383|264.27|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|383||||383|35.75|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|Self-pay|Self-pay|383||||383|134.05|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|383||||383|35.75|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|383||||383|35.75|264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|383||||383||264.27|35.75
32070110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MANDIBLE COMPLETE 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|383||||383||264.27|35.75
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|AARP [1000]|AARP [100000]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|AETNA [1015]|AETNA [101529]|355||||355|32.64|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|355||||355|28.06|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|355||||355|166.85|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|355||||355|75.79|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|355||||355|177.5|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|355||||355|223.65|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|355||||355|28.06|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|355||||355|45.12|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|355||||355|244.95|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|355||||355|101.13|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|355||||355|32.64|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|355||||355|28.06|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|355||||355|32.64|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|355||||355|28.06|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|355||||355|28.06|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|355||||355|244.95|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|355||||355|28.06|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|Self-pay|Self-pay|355||||355|124.25|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|355||||355|28.06|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|355||||355|28.06|244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|355||||355||244.95|28.06
32070140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES LMT < 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|355||||355||244.95|28.06
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AARP [1000]|AARP [100000]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|422||||422|50.45|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|422||||422|39.09|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|422||||422|198.34|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|422||||422|139.64|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|422||||422|211|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|422||||422|265.86|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|422||||422|39.09|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|422||||422|61.21|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|422||||422|291.18|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|422||||422|136.21|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|422||||422|50.45|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|422||||422|39.09|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|422||||422|50.45|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|422||||422|39.09|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|422||||422|39.09|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|422||||422|291.18|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|422||||422|39.09|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|Self-pay|Self-pay|422||||422|147.7|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|422||||422|39.09|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|422||||422|39.09|291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|422||||422||291.18|39.09
32070150|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FACIAL BONES CMPLT 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|422||||422||291.18|39.09
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|AARP [1000]|AARP [100000]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|362||||362|42.65|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|362||||362|31.08|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|362||||362|170.14|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|362||||362|75.79|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|362||||362|181|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|362||||362|228.06|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|362||||362|31.08|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|362||||362|44.02|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|362||||362|249.78|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|362||||362|101.13|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|362||||362|42.65|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|362||||362|31.08|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|362||||362|42.65|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|362||||362|31.08|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|362||||362|31.08|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|362||||362|249.78|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|362||||362|31.08|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|Self-pay|Self-pay|362||||362|126.7|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|362||||362|31.08|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|362||||362|31.08|249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|362||||362||249.78|31.08
32070160|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NASAL BONES COMPLETE 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|362||||362||249.78|31.08
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|AARP [1000]|AARP [100000]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|284||||284|50.45|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|284||||284|40.1|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|284||||284|133.48|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|284||||284|139.64|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|284||||284|142|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|284||||284|178.92|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|284||||284|40.1|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|284||||284|63.34|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|284||||284|195.96|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|284||||284|136.21|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|284||||284|50.45|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|284||||284|40.1|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|284||||284|50.45|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|284||||284|40.1|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|284||||284|40.1|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|284||||284|195.96|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|284||||284|40.1|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|Self-pay|Self-pay|284||||284|99.4|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|284||||284|40.1|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|284||||284|40.1|195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|284||||284||195.96|40.1
32070200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ORBITS COMPLETE 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|284||||284||195.96|40.1
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|AARP [1000]|AARP [100000]|204||||204|130|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|74.1|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|AETNA [1015]|AETNA [101529]|204||||204|34.32|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|28.06|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|73.36|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|73.36|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|28.06|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|73.36|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|44.06|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|78.57|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|34.32|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|28.06|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|73.36|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|34.32|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|28.06|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|28.06|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|28.06|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|Self-pay|Self-pay|204||||204|71.4|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|28.06|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|28.06|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|130|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|73.36|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|73.36|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|130|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|73.36|146.73|28.06
32070210|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL < 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|146.73|146.73|28.06
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|AARP [1000]|AARP [100000]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|39.31|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|35.41|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|75.79|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|35.41|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|57.98|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|101.13|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|39.31|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|35.41|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|39.31|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|35.41|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|35.41|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|35.41|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|Self-pay|Self-pay|216||||216|75.6|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|35.41|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|35.41|149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216||149.04|35.41
32070220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SINUS PARANASAL COMPLETE 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216||149.04|35.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|AARP [1000]|AARP [100000]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|39.31|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|34.41|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|139.64|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|34.41|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|50.99|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|136.21|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|39.31|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|34.41|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|39.31|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|34.41|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|34.41|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|34.41|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|Self-pay|Self-pay|216||||216|75.6|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|34.41|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|34.41|149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216||149.04|34.41
32070250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL < 4 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216||149.04|34.41
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|AARP [1000]|AARP [100000]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|457||||457|46.01|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|457||||457|43.1|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|457||||457|214.79|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|457||||457|139.64|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|457||||457|228.5|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|457||||457|287.91|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|457||||457|43.1|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|457||||457|70.85|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|457||||457|315.33|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|457||||457|136.21|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|457||||457|46.01|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|457||||457|43.1|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|457||||457|46.01|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|457||||457|43.1|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|457||||457|43.1|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|457||||457|315.33|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|457||||457|43.1|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|Self-pay|Self-pay|457||||457|159.95|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|457||||457|43.1|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|457||||457|43.1|315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|457||||457||315.33|43.1
32070260|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SKULL COMPLETE 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|457||||457||315.33|43.1
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AARP [1000]|AARP [100000]|312||||312|130|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|312||||312|74.1|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AETNA [1015]|AETNA [101529]|312||||312|33.19|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|312||||312|26.73|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|312||||312|73.36|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|312||||312|73.36|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS [1155]|BCBS UTHCT [115568]|312||||312|146.64|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|312||||312|75.79|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|312||||312|156|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|312||||312|196.56|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|312||||312|26.73|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|312||||312|73.36|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|CIGNA [1260]|CIGNA GWH [126023]|312||||312|37.56|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|312||||312|215.28|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|312||||312|101.13|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|312||||312|78.57|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|312||||312|33.19|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|312||||312|26.73|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|312||||312|73.36|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|312||||312|33.19|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|312||||312|26.73|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|312||||312|26.73|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|312||||312|215.28|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|312||||312|26.73|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|Self-pay|Self-pay|312||||312|109.2|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|312||||312|26.73|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|312||||312|26.73|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|312||||312|130|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|312||||312|73.36|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|312||||312|73.36|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|312||||312|130|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|312||||312|73.36|215.28|26.73
32070360|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC NECK SOFT TISSUE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|312||||312|146.73|215.28|26.73
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AARP [1000]|AARP [100000]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AETNA [1015]|AETNA [101529]|691||||691|101.11|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|691||||691|84.2|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BCBS UTHCT [115568]|691||||691|324.77|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|691||||691|283.42|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|691||||691|345.5|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|691||||691|435.33|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|691||||691|84.2|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|CIGNA [1260]|CIGNA GWH [126023]|691||||691|151.76|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|691||||691|476.79|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|691||||691|287.66|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|691||||691|101.11|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|691||||691|84.2|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|691||||691|101.11|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|691||||691|84.2|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|691||||691|84.2|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|691||||691|476.79|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|691||||691|84.2|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|Self-pay|Self-pay|691||||691|241.85|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|691||||691|84.2|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|691||||691|84.2|476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|691||||691||476.79|84.2
32070371|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPEECH EVAL COMPLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|691||||691||476.79|84.2
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AARP [1000]|AARP [100000]|369||||369|130|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|369||||369|74.1|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AETNA [1015]|AETNA [101529]|369||||369|25.42|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|369||||369|20.71|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|369||||369|73.36|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|369||||369|73.36|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS [1155]|BCBS UTHCT [115568]|369||||369|173.43|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|369||||369|75.79|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|369||||369|184.5|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|369||||369|232.47|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|369||||369|20.71|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|369||||369|73.36|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|CIGNA [1260]|CIGNA GWH [126023]|369||||369|202.95|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|369||||369|254.61|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|369||||369|101.13|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|369||||369|78.57|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|369||||369|25.42|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|369||||369|20.71|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|369||||369|73.36|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|369||||369|25.42|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|369||||369|20.71|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|369||||369|20.71|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|369||||369|254.61|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|369||||369|20.71|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|Self-pay|Self-pay|369||||369|129.15|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|369||||369|20.71|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|369||||369|20.71|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|369||||369|130|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|369||||369|73.36|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|369||||369|73.36|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|369||||369|130|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|369||||369|73.36|254.61|20.71
32071045|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST SINGLE VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|369||||369|146.73|254.61|20.71
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AARP [1000]|AARP [100000]|323||||323|130|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|323||||323|74.1|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AETNA [1015]|AETNA [101529]|323||||323|33.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|323||||323|28.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|323||||323|73.36|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|323||||323|73.36|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|323||||323|151.81|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|323||||323|75.79|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|323||||323|161.5|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|323||||323|203.49|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|323||||323|28.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|323||||323|73.36|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|323||||323|177.65|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|323||||323|222.87|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|323||||323|101.13|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|323||||323|78.57|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|323||||323|33.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|323||||323|28.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|323||||323|73.36|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|323||||323|33.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|323||||323|28.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|323||||323|28.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|323||||323|222.87|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|323||||323|28.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|Self-pay|Self-pay|323||||323|113.05|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|323||||323|28.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|323||||323|28.74|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|323||||323|130|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|323||||323|73.36|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|323||||323|73.36|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|323||||323|130|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|323||||323|73.36|222.87|28.74
32071046|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|323||||323|146.73|222.87|28.74
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|AARP [1000]|AARP [100000]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|AETNA [1015]|AETNA [101529]|243||||243|42.65|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|243||||243|36.75|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|243||||243|114.21|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|243||||243|75.79|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|243||||243|121.5|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|243||||243|153.09|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|243||||243|36.75|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|243||||243|133.65|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|243||||243|167.67|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|243||||243|101.13|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|243||||243|42.65|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|243||||243|36.75|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|243||||243|42.65|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|243||||243|36.75|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|243||||243|36.75|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|243||||243|167.67|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|243||||243|36.75|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|Self-pay|Self-pay|243||||243|85.05|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|243||||243|36.75|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|243||||243|36.75|167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|243||||243||167.67|36.75
32071047|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|243||||243||167.67|36.75
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AARP [1000]|AARP [100000]|315||||315|130|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|315||||315|99.8|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|315||||315|44.33|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|315||||315|39.43|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|315||||315|98.82|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|315||||315|98.82|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|315||||315|148.05|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|315||||315|139.64|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|315||||315|157.5|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|315||||315|198.45|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|315||||315|39.43|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|315||||315|98.82|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|315||||315|173.25|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|315||||315|217.35|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|315||||315|136.21|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|315||||315|105.83|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|315||||315|44.33|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|315||||315|39.43|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|315||||315|98.82|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|315||||315|44.33|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|315||||315|39.43|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|315||||315|39.43|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|315||||315|217.35|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|315||||315|39.43|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|Self-pay|Self-pay|315||||315|110.25|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|315||||315|39.43|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|315||||315|39.43|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|315||||315|130|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|315||||315|98.82|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|315||||315|98.82|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|315||||315|130|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|315||||315|98.82|217.35|39.43
32071048|EAP|0324 - RADIOLOGY-DIAGNOSTIC-CHEST X-RAY|HC CHEST 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|315||||315|197.63|217.35|39.43
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|AARP [1000]|AARP [100000]|408||||408|130|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|408||||408|74.1|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|AETNA [1015]|AETNA [101529]|408||||408|37.66|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|408||||408|31.41|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|408||||408|73.36|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|408||||408|73.36|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|408||||408|191.76|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|408||||408|75.79|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|408||||408|204|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|408||||408|257.04|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|408||||408|31.41|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|408||||408|73.36|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|408||||408|46.7|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|408||||408|281.52|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|408||||408|101.13|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|408||||408|78.57|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|408||||408|37.66|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|408||||408|31.41|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|408||||408|73.36|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|408||||408|37.66|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|408||||408|31.41|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|408||||408|31.41|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|408||||408|281.52|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|408||||408|31.41|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|Self-pay|Self-pay|408||||408|142.8|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|408||||408|31.41|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|408||||408|31.41|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|408||||408|130|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|408||||408|73.36|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|408||||408|73.36|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|408||||408|130|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|408||||408|73.36|281.52|31.41
32071100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|408||||408|146.73|281.52|31.41
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AARP [1000]|AARP [100000]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AETNA [1015]|AETNA [101529]|480||||480|42.65|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|480||||480|36.09|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS [1155]|BCBS UTHCT [115568]|480||||480|225.6|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|480||||480|139.64|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|480||||480|240|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|480||||480|302.4|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|480||||480|36.09|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|CIGNA [1260]|CIGNA GWH [126023]|480||||480|56.33|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|480||||480|331.2|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|480||||480|136.21|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|480||||480|42.65|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|480||||480|36.09|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|480||||480|42.65|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|480||||480|36.09|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|480||||480|36.09|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|480||||480|331.2|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|480||||480|36.09|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|Self-pay|Self-pay|480||||480|168|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|480||||480|36.09|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|480||||480|36.09|331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|480||||480||331.2|36.09
32071101|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS UNILAT W/CHEST 3+ VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|480||||480||331.2|36.09
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|AARP [1000]|AARP [100000]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|43.78|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|37.76|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|139.64|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|37.76|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|60.12|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|136.21|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|43.78|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|37.76|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|43.78|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|37.76|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|37.76|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|37.76|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|Self-pay|Self-pay|216||||216|75.6|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|37.76|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|37.76|149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216||149.04|37.76
32071110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216||149.04|37.76
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|AARP [1000]|AARP [100000]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|406||||406|54.34|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|406||||406|44.44|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|406||||406|190.82|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|406||||406|139.64|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|406||||406|203|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|406||||406|255.78|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|406||||406|44.44|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|406||||406|74.09|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|406||||406|280.14|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|406||||406|136.21|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|406||||406|54.34|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|406||||406|44.44|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|406||||406|54.34|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|406||||406|44.44|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|406||||406|44.44|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|406||||406|280.14|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|406||||406|44.44|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|Self-pay|Self-pay|406||||406|142.1|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|406||||406|44.44|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|406||||406|44.44|280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|406||||406||280.14|44.44
32071111|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RIBS BILAT W/CHEST 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|406||||406||280.14|44.44
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|AARP [1000]|AARP [100000]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|316||||316|34.87|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|316||||316|28.06|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|316||||316|148.52|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|316||||316|75.79|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|316||||316|158|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|316||||316|199.08|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|316||||316|28.06|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|316||||316|48.88|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|316||||316|218.04|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|316||||316|101.13|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|316||||316|34.87|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|316||||316|28.06|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|316||||316|34.87|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|316||||316|28.06|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|316||||316|28.06|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|316||||316|218.04|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|316||||316|28.06|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|Self-pay|Self-pay|316||||316|110.6|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|316||||316|28.06|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|316||||316|28.06|218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|316||||316||218.04|28.06
32071120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNUM 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|316||||316||218.04|28.06
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|AARP [1000]|AARP [100000]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|214||||214|44.33|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|34.09|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|214||||214|100.58|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|75.79|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|107|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|134.82|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|34.09|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|214||||214|53.7|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214||||214|101.13|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|44.33|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|34.09|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|44.33|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|34.09|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214||||214|34.09|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|34.09|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|Self-pay|Self-pay|214||||214|74.9|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214||||214|34.09|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|34.09|147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214||147.66|34.09
32071130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC STERNO-CLAVICULAR JOINT(S) 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214||147.66|34.09
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|AARP [1000]|AARP [100000]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|AETNA [1015]|AETNA [101529]|251||||251|24.84|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|251||||251|21.05|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|BCBS [1155]|BCBS UTHCT [115568]|251||||251|117.97|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|251||||251|75.79|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|251||||251|125.5|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|251||||251|158.13|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|251||||251|21.05|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|CIGNA [1260]|CIGNA GWH [126023]|251||||251|33.82|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|251||||251|173.19|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|251||||251|101.13|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|251||||251|24.84|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|251||||251|21.05|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|251||||251|24.84|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|251||||251|21.05|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|251||||251|21.05|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|251||||251|173.19|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|251||||251|21.05|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|Self-pay|Self-pay|251||||251|87.85|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|251||||251|21.05|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|251||||251|21.05|173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|251||||251||173.19|21.05
32072020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE SINGLE VIEW ANY LEVEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|251||||251||173.19|21.05
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|AARP [1000]|AARP [100000]|216||||216|130|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216|74.1|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|41.54|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|31.41|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216|73.36|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216|73.36|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|75.79|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|31.41|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216|73.36|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|51.55|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|101.13|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216|78.57|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|41.54|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|31.41|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216|73.36|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|41.54|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|31.41|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|31.41|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|31.41|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|Self-pay|Self-pay|216||||216|75.6|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|31.41|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|31.41|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216|130|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216|73.36|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216|73.36|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216|130|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216|73.36|149.04|31.41
32072040|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 2 OR 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216|146.73|149.04|31.41
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AARP [1000]|AARP [100000]|344||||344|130|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|344||||344|99.8|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AETNA [1015]|AETNA [101529]|344||||344|57.12|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|344||||344|42.78|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|344||||344|98.82|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|344||||344|98.82|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|344||||344|161.68|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|344||||344|139.64|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|344||||344|172|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|344||||344|216.72|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|344||||344|42.78|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|344||||344|98.82|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|344||||344|73.56|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|344||||344|237.36|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|344||||344|136.21|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|344||||344|105.83|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|344||||344|57.12|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|344||||344|42.78|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|344||||344|98.82|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|344||||344|57.12|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|344||||344|42.78|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|344||||344|42.78|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|344||||344|237.36|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|344||||344|42.78|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|Self-pay|Self-pay|344||||344|120.4|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|344||||344|42.78|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|344||||344|42.78|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|344||||344|130|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|344||||344|98.82|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|344||||344|98.82|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|344||||344|130|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|344||||344|98.82|237.36|42.78
32072050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 4 OR 5 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|344||||344|197.63|237.36|42.78
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|AARP [1000]|AARP [100000]|344||||344|130|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|344||||344|99.8|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|AETNA [1015]|AETNA [101529]|344||||344|68.81|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|344||||344|52.79|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|344||||344|98.82|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|344||||344|98.82|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|344||||344|161.68|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|344||||344|139.64|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|344||||344|172|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|344||||344|216.72|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|344||||344|52.79|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|344||||344|98.82|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|344||||344|92.36|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|344||||344|237.36|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|344||||344|136.21|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|344||||344|105.83|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|344||||344|68.81|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|344||||344|52.79|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|344||||344|98.82|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|344||||344|68.81|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|344||||344|52.79|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|344||||344|52.79|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|344||||344|237.36|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|344||||344|52.79|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|Self-pay|Self-pay|344||||344|120.4|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|344||||344|52.79|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|344||||344|52.79|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|344||||344|130|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|344||||344|98.82|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|344||||344|98.82|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|344||||344|130|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|344||||344|98.82|237.36|52.79
32072052|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CERVICAL SPINE 6+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|344||||344|197.63|237.36|52.79
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|AARP [1000]|AARP [100000]|216||||216|130|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216|99.8|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|33.19|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|32.08|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216|98.82|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216|98.82|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|139.64|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|32.08|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216|98.82|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|49.39|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|136.21|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216|105.83|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|33.19|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|32.08|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216|98.82|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|33.19|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|32.08|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|32.08|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|32.08|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|Self-pay|Self-pay|216||||216|75.6|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|32.08|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|32.08|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216|130|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216|98.82|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216|98.82|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216|130|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216|98.82|197.63|32.08
32072070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216|197.63|197.63|32.08
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|AARP [1000]|AARP [100000]|484||||484|130|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|484||||484|99.8|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|AETNA [1015]|AETNA [101529]|484||||484|41.54|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|484||||484|32.75|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|484||||484|98.82|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|484||||484|98.82|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|484||||484|227.48|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|484||||484|139.64|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|484||||484|242|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|484||||484|304.92|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|484||||484|32.75|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|484||||484|98.82|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|484||||484|55.34|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|484||||484|333.96|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|484||||484|136.21|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|484||||484|105.83|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|484||||484|41.54|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|484||||484|32.75|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|484||||484|98.82|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|484||||484|41.54|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|484||||484|32.75|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|484||||484|32.75|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|484||||484|333.96|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|484||||484|32.75|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|Self-pay|Self-pay|484||||484|169.4|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|484||||484|32.75|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|484||||484|32.75|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|484||||484|130|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|484||||484|98.82|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|484||||484|98.82|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|484||||484|130|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|484||||484|98.82|333.96|32.75
32072072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|484||||484|197.63|333.96|32.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|AARP [1000]|AARP [100000]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|577||||577|47.66|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|577||||577|36.75|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|577||||577|271.19|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|577||||577|139.64|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|577||||577|288.5|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|577||||577|363.51|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|577||||577|36.75|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|577||||577|65.59|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|577||||577|398.13|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|577||||577|136.21|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|577||||577|47.66|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|577||||577|36.75|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|577||||577|47.66|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|577||||577|36.75|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|577||||577|36.75|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|577||||577|398.13|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|577||||577|36.75|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|Self-pay|Self-pay|577||||577|201.95|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|577||||577|36.75|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|577||||577|36.75|398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|577||||577||398.13|36.75
32072074|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC THORACIC SPINE 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|577||||577||398.13|36.75
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|AARP [1000]|AARP [100000]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|AETNA [1015]|AETNA [101529]|163||||163|43.78|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163||||163|36.43|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|BCBS [1155]|BCBS UTHCT [115568]|163||||163|76.61|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163||||163|75.79|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163||||163|81.5|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163||||163|102.69|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163||||163|36.43|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|CIGNA [1260]|CIGNA GWH [126023]|163||||163|89.65|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163||||163|112.47|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|163||||163|101.13|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163||||163|43.78|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163||||163|36.43|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163||||163|43.78|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163||||163|36.43|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|163||||163|36.43|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163||||163|112.47|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163||||163|36.43|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|Self-pay|Self-pay|163||||163|57.05|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|163||||163|36.43|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163||||163|36.43|112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163||||163||112.47|36.43
32072081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC T-L-SPINE SCOLIOSIS 1 VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163||||163||112.47|36.43
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|AARP [1000]|AARP [100000]|232||||232|130|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|232||||232|99.8|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|AETNA [1015]|AETNA [101529]|232||||232|41.54|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|232||||232|33.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|232||||232|98.82|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|232||||232|98.82|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|232||||232|109.04|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|232||||232|139.64|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|232||||232|116|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|232||||232|146.16|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|232||||232|33.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|232||||232|98.82|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|232||||232|54.24|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|232||||232|160.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|232||||232|136.21|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|232||||232|105.83|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|232||||232|41.54|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|232||||232|33.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|232||||232|98.82|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|232||||232|41.54|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|232||||232|33.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|232||||232|33.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|232||||232|160.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|232||||232|33.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|Self-pay|Self-pay|232||||232|81.2|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|232||||232|33.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|232||||232|33.08|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|232||||232|130|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|232||||232|98.82|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|232||||232|98.82|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|232||||232|130|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|232||||232|98.82|197.63|33.08
32072100|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 2 OR 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|232||||232|197.63|197.63|33.08
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|AARP [1000]|AARP [100000]|344||||344|130|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|344||||344|99.8|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|344||||344|54.91|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|344||||344|46.11|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|344||||344|98.82|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|344||||344|98.82|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|344||||344|161.68|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|344||||344|139.64|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|344||||344|172|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|344||||344|216.72|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|344||||344|46.11|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|344||||344|98.82|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|344||||344|75.72|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|344||||344|237.36|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|344||||344|136.21|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|344||||344|105.83|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|344||||344|54.91|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|344||||344|46.11|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|344||||344|98.82|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|344||||344|54.91|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|344||||344|46.11|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|344||||344|46.11|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|344||||344|237.36|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|344||||344|46.11|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|Self-pay|Self-pay|344||||344|120.4|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|344||||344|46.11|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|344||||344|46.11|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|344||||344|130|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|344||||344|98.82|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|344||||344|98.82|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|344||||344|130|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|344||||344|98.82|237.36|46.11
32072110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE LUMBOSACRAL 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|344||||344|197.63|237.36|46.11
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|AARP [1000]|AARP [100000]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|AETNA [1015]|AETNA [101529]|602||||602|68.81|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|602||||602|58.14|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|602||||602|282.94|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|602||||602|139.64|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|602||||602|301|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|602||||602|379.26|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|602||||602|58.14|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|602||||602|98.28|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|602||||602|415.38|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|602||||602|136.21|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|602||||602|68.81|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|602||||602|58.14|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|602||||602|68.81|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|602||||602|58.14|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|602||||602|58.14|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|602||||602|415.38|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|602||||602|58.14|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|Self-pay|Self-pay|602||||602|210.7|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|602||||602|58.14|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|602||||602|58.14|415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|602||||602||415.38|58.14
32072114|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SPINE L/S COMPLETE W/BENDING 6+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|602||||602||415.38|58.14
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|AARP [1000]|AARP [100000]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|AETNA [1015]|AETNA [101529]|316||||316|43.78|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|316||||316|38.43|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|316||||316|148.52|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|316||||316|139.64|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|316||||316|158|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|316||||316|199.08|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|316||||316|38.43|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|316||||316|68.27|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|316||||316|218.04|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|316||||316|136.21|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|316||||316|43.78|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|316||||316|38.43|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|316||||316|43.78|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|316||||316|38.43|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|316||||316|38.43|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|316||||316|218.04|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|316||||316|38.43|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|Self-pay|Self-pay|316||||316|110.6|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|316||||316|38.43|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|316||||316|38.43|218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|316||||316||218.04|38.43
32072120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC L-S SPINE BENDING ONLY 2 OR 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|316||||316||218.04|38.43
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|AARP [1000]|AARP [100000]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|30.41|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|30.08|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|139.64|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|30.08|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|38.64|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|136.21|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|30.41|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|30.08|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|30.41|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|30.08|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|30.08|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|30.08|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|Self-pay|Self-pay|216||||216|75.6|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|30.08|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|30.08|149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216||149.04|30.08
32072170|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS 1 OR 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216||149.04|30.08
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|AARP [1000]|AARP [100000]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|450||||450|43.22|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450||||450|35.75|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|450||||450|211.5|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450||||450|139.64|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450||||450|225|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450||||450|283.5|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450||||450|35.75|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|450||||450|54.79|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|450||||450|310.5|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|450||||450|136.21|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450||||450|43.22|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450||||450|35.75|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450||||450|43.22|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450||||450|35.75|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|450||||450|35.75|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|450||||450|310.5|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450||||450|35.75|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|Self-pay|Self-pay|450||||450|157.5|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|450||||450|35.75|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450||||450|35.75|310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450||||450||310.5|35.75
32072190|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC PELVIS COMPLETE 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450||||450||310.5|35.75
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|AARP [1000]|AARP [100000]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|AETNA [1015]|AETNA [101529]|161||||161|35.98|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161||||161|26.73|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|161||||161|75.67|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161||||161|139.64|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161||||161|80.5|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161||||161|101.43|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161||||161|26.73|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|161||||161|41.33|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|161||||161|111.09|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|161||||161|136.21|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161||||161|35.98|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161||||161|26.73|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161||||161|35.98|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161||||161|26.73|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|161||||161|26.73|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|161||||161|111.09|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161||||161|26.73|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|Self-pay|Self-pay|161||||161|56.35|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|161||||161|26.73|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161||||161|26.73|139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161||||161||139.64|26.73
32072200|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS < 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161||||161||139.64|26.73
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|AARP [1000]|AARP [100000]|378||||378|130|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|378||||378|99.8|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|378||||378|40.99|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|378||||378|31.08|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|378||||378|98.82|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|378||||378|98.82|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|378||||378|177.66|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|378||||378|139.64|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|378||||378|189|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|378||||378|238.14|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|378||||378|31.08|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|378||||378|98.82|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|378||||378|49.96|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|378||||378|260.82|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|378||||378|136.21|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|378||||378|105.83|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|378||||378|40.99|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|378||||378|31.08|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|378||||378|98.82|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|378||||378|40.99|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|378||||378|31.08|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|378||||378|31.08|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|378||||378|260.82|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|378||||378|31.08|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|Self-pay|Self-pay|378||||378|132.3|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|378||||378|31.08|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|378||||378|31.08|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|378||||378|130|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|378||||378|98.82|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|378||||378|98.82|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|378||||378|130|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|378||||378|98.82|260.82|31.08
32072202|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACROILIAC JOINTS 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|378||||378|197.63|260.82|31.08
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AARP [1000]|AARP [100000]|335||||335|130|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|335||||335|74.1|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|335||||335|34.87|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|335||||335|26.73|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|335||||335|73.36|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|335||||335|73.36|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|335||||335|157.45|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|335||||335|75.79|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|335||||335|167.5|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|335||||335|211.05|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|335||||335|26.73|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|335||||335|73.36|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|335||||335|43.51|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|335||||335|231.15|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|335||||335|101.13|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|335||||335|78.57|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|335||||335|34.87|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|335||||335|26.73|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|335||||335|73.36|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|335||||335|34.87|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|335||||335|26.73|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|335||||335|26.73|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|335||||335|231.15|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|335||||335|26.73|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|Self-pay|Self-pay|335||||335|117.25|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|335||||335|26.73|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|335||||335|26.73|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|335||||335|130|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|335||||335|73.36|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|335||||335|73.36|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|335||||335|130|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|335||||335|73.36|231.15|26.73
32072220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SACRUM/COCCYX 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|335||||335|146.73|231.15|26.73
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|AARP [1000]|AARP [100000]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|AETNA [1015]|AETNA [101529]|350||||350|35.42|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|350||||350|26.4|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|350||||350|164.5|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|350||||350|75.79|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|350||||350|175|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|350||||350|220.5|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|350||||350|26.4|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|350||||350|39.18|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|350||||350|241.5|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|350||||350|101.13|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|350||||350|35.42|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|350||||350|26.4|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|350||||350|35.42|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|350||||350|26.4|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|350||||350|26.4|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|350||||350|241.5|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|350||||350|26.4|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|Self-pay|Self-pay|350||||350|122.5|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|350||||350|26.4|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|350||||350|26.4|241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|350||||350||241.5|26.4
32073000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CLAVICLE COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|350||||350||241.5|26.4
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|AARP [1000]|AARP [100000]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|AETNA [1015]|AETNA [101529]|302||||302|28.75|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|302||||302|28.74|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|302||||302|141.94|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|302||||302|139.64|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|302||||302|151|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|302||||302|190.26|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|302||||302|28.74|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|302||||302|40.78|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|302||||302|208.38|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|302||||302|136.21|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|302||||302|28.75|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|302||||302|28.74|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|302||||302|28.75|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|302||||302|28.74|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|302||||302|28.74|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|302||||302|208.38|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|302||||302|28.74|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|Self-pay|Self-pay|302||||302|105.7|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|302||||302|28.74|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|302||||302|28.74|208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|302||||302||208.38|28.74
32073010|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SCAPULA COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|302||||302||208.38|28.74
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AARP [1000]|AARP [100000]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AETNA [1015]|AETNA [101529]|300||||300|20.95|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|21.71|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|75.79|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|21.71|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|34.36|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|101.13|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|20.95|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|21.71|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|20.95|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|21.71|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|21.71|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|21.71|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|Self-pay|Self-pay|300||||300|105|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|21.71|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|21.71|207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||207|20.95
32073020|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER 1 VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||207|20.95
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|AARP [1000]|AARP [100000]|216||||216|130|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216|74.1|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|36.53|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|27.74|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216|73.36|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216|73.36|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|75.79|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|27.74|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216|73.36|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|43.51|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|101.13|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216|78.57|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|36.53|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|27.74|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216|73.36|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|36.53|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|27.74|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|27.74|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|27.74|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|Self-pay|Self-pay|216||||216|75.6|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|27.74|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|27.74|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216|130|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216|73.36|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216|73.36|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216|130|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216|73.36|149.04|27.74
32073030|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SHOULDER COMPLETE 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216|146.73|149.04|27.74
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AARP [1000]|AARP [100000]|348||||348|130|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|348||||348|74.1|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|348||||348|35.42|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|348||||348|27.4|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|348||||348|73.36|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|348||||348|73.36|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|348||||348|163.56|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|348||||348|75.79|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|348||||348|174|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|348||||348|219.24|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|348||||348|27.4|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|348||||348|73.36|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|348||||348|42.98|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|348||||348|240.12|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|348||||348|101.13|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|348||||348|78.57|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|348||||348|35.42|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|348||||348|27.4|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|348||||348|73.36|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|348||||348|35.42|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|348||||348|27.4|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|348||||348|27.4|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|348||||348|240.12|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|348||||348|27.4|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|Self-pay|Self-pay|348||||348|121.8|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|348||||348|27.4|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|348||||348|27.4|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|348||||348|130|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|348||||348|73.36|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|348||||348|73.36|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|348||||348|130|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|348||||348|73.36|240.12|27.4
32073060|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HUMERUS 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|348||||348|146.73|240.12|27.4
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|AARP [1000]|AARP [100000]|161||||161|130|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161||||161|74.1|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|AETNA [1015]|AETNA [101529]|161||||161|30.96|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161||||161|25.73|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161||||161|73.36|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161||||161|73.36|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|161||||161|75.67|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161||||161|75.79|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161||||161|80.5|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161||||161|101.43|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161||||161|25.73|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161||||161|73.36|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|161||||161|38.66|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|161||||161|111.09|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|161||||161|101.13|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161||||161|78.57|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161||||161|30.96|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161||||161|25.73|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161||||161|73.36|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161||||161|30.96|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161||||161|25.73|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|161||||161|25.73|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|161||||161|111.09|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161||||161|25.73|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|Self-pay|Self-pay|161||||161|56.35|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|161||||161|25.73|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161||||161|25.73|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161||||161|130|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|161||||161|73.36|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|161||||161|73.36|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161||||161|130|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161||||161|73.36|146.73|25.73
32073070|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161||||161|146.73|146.73|25.73
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|AARP [1000]|AARP [100000]|204||||204|130|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|74.1|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|204||||204|34.32|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|29.74|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|73.36|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|73.36|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|29.74|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|73.36|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|47.82|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|78.57|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|34.32|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|29.74|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|73.36|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|34.32|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|29.74|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|29.74|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|29.74|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|Self-pay|Self-pay|204||||204|71.4|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|29.74|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|29.74|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|130|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|73.36|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|73.36|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|130|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|73.36|146.73|29.74
32073080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ELBOW COMPLETE 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|146.73|146.73|29.74
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|AARP [1000]|AARP [100000]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|AETNA [1015]|AETNA [101529]|209||||209|34.32|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|209||||209|100.69|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|BCBS [1155]|BCBS UTHCT [115568]|209||||209|98.23|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|209||||209|139.64|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|209||||209|104.5|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|209||||209|131.67|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|209||||209|100.69|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|CIGNA [1260]|CIGNA GWH [126023]|209||||209|39.18|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|209||||209|144.21|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|209||||209|136.21|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|209||||209|34.32|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|209||||209|100.69|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|209||||209|34.32|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|209||||209|100.69|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|209||||209|100.69|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|209||||209|144.21|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|209||||209|100.69|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|Self-pay|Self-pay|209||||209|73.15|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|209||||209|100.69|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|209||||209|100.69|144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|209||||209||144.21|34.32
32073092|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UPPER EXT INFANT 2+ VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|209||||209||144.21|34.32
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AARP [1000]|AARP [100000]|299||||299|130|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|299||||299|74.1|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|299||||299|46.56|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|299||||299|33.08|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|299||||299|73.36|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|299||||299|73.36|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|299||||299|140.53|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|299||||299|75.79|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|299||||299|149.5|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|299||||299|188.37|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|299||||299|33.08|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|299||||299|73.36|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|299||||299|46.16|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|299||||299|206.31|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|299||||299|101.13|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|299||||299|78.57|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|299||||299|46.56|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|299||||299|33.08|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|299||||299|73.36|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|299||||299|46.56|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|299||||299|33.08|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|299||||299|33.08|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|299||||299|206.31|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|299||||299|33.08|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|Self-pay|Self-pay|299||||299|104.65|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|299||||299|33.08|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|299||||299|33.08|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|299||||299|130|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|299||||299|73.36|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|299||||299|73.36|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|299||||299|130|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|299||||299|73.36|206.31|33.08
32073110|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC WRIST COMPLETE 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|299||||299|146.73|206.31|33.08
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AARP [1000]|AARP [100000]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AETNA [1015]|AETNA [101529]|261||||261|33.74|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|261||||261|26.73|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|261||||261|122.67|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|261||||261|139.64|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|261||||261|130.5|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|261||||261|164.43|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|261||||261|26.73|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|261||||261|38.65|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|261||||261|180.09|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|261||||261|136.21|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|261||||261|33.74|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|261||||261|26.73|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|261||||261|33.74|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|261||||261|26.73|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|261||||261|26.73|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|261||||261|180.09|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|261||||261|26.73|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|Self-pay|Self-pay|261||||261|91.35|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|261||||261|26.73|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|261||||261|26.73|180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|261||||261||180.09|26.73
32073120|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|261||||261||180.09|26.73
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AARP [1000]|AARP [100000]|204||||204|130|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|74.1|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|204||||204|40.44|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|30.08|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|73.36|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|73.36|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|30.08|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|73.36|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|43.48|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|78.57|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|40.44|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|30.08|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|73.36|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|40.44|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|30.08|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|30.08|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|30.08|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|Self-pay|Self-pay|204||||204|71.4|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|30.08|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|30.08|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|130|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|73.36|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|73.36|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|130|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|73.36|146.73|30.08
32073130|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HAND 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|146.73|146.73|30.08
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|AARP [1000]|AARP [100000]|204||||204|130|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|74.1|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|204||||204|44.33|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|30.4|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|73.36|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|73.36|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|30.4|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|73.36|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|38.15|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|78.57|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|44.33|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|30.4|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|73.36|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|44.33|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|30.4|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|30.4|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|30.4|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|Self-pay|Self-pay|204||||204|71.4|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|30.4|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|30.4|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|130|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|73.36|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|73.36|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|130|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|73.36|146.73|30.4
32073140|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FINGER(S) 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|146.73|146.73|30.4
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|AARP [1000]|AARP [100000]|204||||204|130|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|74.1|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|AETNA [1015]|AETNA [101529]|204||||204|52.68|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|39.09|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|73.36|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|73.36|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|39.09|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|73.36|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|112.2|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|78.57|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|52.68|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|39.09|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|73.36|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|52.68|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|39.09|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|39.09|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|39.09|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|Self-pay|Self-pay|204||||204|71.4|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|39.09|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|39.09|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|130|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|73.36|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|73.36|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|130|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|73.36|146.73|39.09
32073502|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 2-3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|146.73|146.73|39.09
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|AARP [1000]|AARP [100000]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|270||||270|65.47|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|270||||270|48.79|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|270||||270|126.9|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|270||||270|139.64|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|270||||270|135|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|270||||270|170.1|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|270||||270|48.79|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|270||||270|148.5|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|270||||270|186.3|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|270||||270|136.21|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|270||||270|65.47|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|270||||270|48.79|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|270||||270|65.47|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|270||||270|48.79|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|270||||270|48.79|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|270||||270|186.3|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|270||||270|48.79|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|Self-pay|Self-pay|270||||270|94.5|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|270||||270|48.79|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|270||||270|48.79|186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|270||||270||186.3|48.79
32073503|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIP UNILAT 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|270||||270||186.3|48.79
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|AARP [1000]|AARP [100000]|270||||270|130|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|270||||270|99.8|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|AETNA [1015]|AETNA [101529]|270||||270|44.33|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|270||||270|35.41|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|270||||270|98.82|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|270||||270|98.82|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|270||||270|126.9|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|270||||270|139.64|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|270||||270|135|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|270||||270|170.1|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|270||||270|35.41|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|270||||270|98.82|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|270||||270|148.5|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|270||||270|186.3|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|270||||270|136.21|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|270||||270|105.83|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|270||||270|44.33|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|270||||270|35.41|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|270||||270|98.82|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|270||||270|44.33|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|270||||270|35.41|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|270||||270|35.41|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|270||||270|186.3|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|270||||270|35.41|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|Self-pay|Self-pay|270||||270|94.5|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|270||||270|35.41|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|270||||270|35.41|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|270||||270|130|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|270||||270|98.82|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|270||||270|98.82|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|270||||270|130|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|270||||270|98.82|197.63|35.41
32073521|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|270||||270|197.63|197.63|35.41
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AARP [1000]|AARP [100000]|270||||270|130|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|270||||270|99.8|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AETNA [1015]|AETNA [101529]|270||||270|57.7|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|270||||270|46.11|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|270||||270|98.82|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|270||||270|98.82|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|270||||270|126.9|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|270||||270|139.64|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|270||||270|135|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|270||||270|170.1|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|270||||270|46.11|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|270||||270|98.82|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|270||||270|148.5|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|270||||270|186.3|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|270||||270|136.21|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|270||||270|105.83|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|270||||270|57.7|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|270||||270|46.11|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|270||||270|98.82|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|270||||270|57.7|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|270||||270|46.11|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|270||||270|46.11|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|270||||270|186.3|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|270||||270|46.11|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|Self-pay|Self-pay|270||||270|94.5|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|270||||270|46.11|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|270||||270|46.11|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|270||||270|130|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|270||||270|98.82|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|270||||270|98.82|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|270||||270|130|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|270||||270|98.82|197.63|46.11
32073522|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 3-4 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|270||||270|197.63|197.63|46.11
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|AARP [1000]|AARP [100000]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|AETNA [1015]|AETNA [101529]|515||||515|67.15|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|515||||515|53.46|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|515||||515|242.05|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|515||||515|49.91|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|515||||515|257.5|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|515||||515|324.45|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|515||||515|53.46|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|515||||515|283.25|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|515||||515|355.35|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|515||||515|136.21|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|515||||515|67.15|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|515||||515|53.46|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|515||||515|67.15|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|515||||515|53.46|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|515||||515|53.46|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|515||||515|355.35|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|515||||515|53.46|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|Self-pay|Self-pay|515||||515|180.25|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|515||||515|53.46|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|515||||515|53.46|355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|515||||515||355.35|49.91
32073523|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HIPS BILAT 5+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|515||||515||355.35|49.91
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|AARP [1000]|AARP [100000]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|370||||370|39.31|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|370||||370|31.08|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|370||||370|173.9|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|370||||370|75.79|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|370||||370|185|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|370||||370|233.1|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|370||||370|31.08|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|370||||370|203.5|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|370||||370|255.3|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|370||||370|101.13|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|370||||370|39.31|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|370||||370|31.08|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|370||||370|39.31|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|370||||370|31.08|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|370||||370|31.08|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|370||||370|255.3|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|370||||370|31.08|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|Self-pay|Self-pay|370||||370|129.5|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|370||||370|31.08|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|370||||370|31.08|255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|370||||370||255.3|31.08
32073552|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FEMUR 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|370||||370||255.3|31.08
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|AARP [1000]|AARP [100000]|204||||204|130|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|74.1|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|AETNA [1015]|AETNA [101529]|204||||204|38.76|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|29.4|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|73.36|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|73.36|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|29.4|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|73.36|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|40.78|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|78.57|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|38.76|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|29.4|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|73.36|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|38.76|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|29.4|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|29.4|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|29.4|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|Self-pay|Self-pay|204||||204|71.4|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|29.4|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|29.4|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|130|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|73.36|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|73.36|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|130|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|73.36|146.73|29.4
32073560|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 1 OR 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|146.73|146.73|29.4
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|AARP [1000]|AARP [100000]|216||||216|130|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216|74.1|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|46.01|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|33.75|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216|73.36|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216|73.36|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|75.79|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|33.75|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216|73.36|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|47.82|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|101.13|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216|78.57|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|46.01|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|33.75|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216|73.36|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|46.01|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|33.75|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|33.75|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|33.75|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|Self-pay|Self-pay|216||||216|75.6|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|33.75|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|33.75|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216|130|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216|73.36|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216|73.36|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216|130|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216|73.36|149.04|33.75
32073562|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE 3 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216|146.73|149.04|33.75
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|AARP [1000]|AARP [100000]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|AETNA [1015]|AETNA [101529]|264||||264|50.45|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|264||||264|37.43|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|264||||264|124.08|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|264||||264|139.64|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|264||||264|132|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|264||||264|166.32|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|264||||264|37.43|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|264||||264|54.24|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|264||||264|182.16|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|264||||264|136.21|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|264||||264|50.45|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|264||||264|37.43|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|264||||264|50.45|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|264||||264|37.43|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|264||||264|37.43|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|264||||264|182.16|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|264||||264|37.43|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|Self-pay|Self-pay|264||||264|92.4|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|264||||264|37.43|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|264||||264|37.43|182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|264||||264||182.16|37.43
32073564|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEE COMPLETE 4+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|264||||264||182.16|37.43
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|AARP [1000]|AARP [100000]|204||||204|130|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|74.1|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|AETNA [1015]|AETNA [101529]|204||||204|46.56|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|33.75|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|73.36|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|73.36|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|33.75|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|73.36|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|41.86|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|78.57|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|46.56|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|33.75|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|73.36|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|46.56|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|33.75|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|33.75|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|33.75|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|Self-pay|Self-pay|204||||204|71.4|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|33.75|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|33.75|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|130|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|73.36|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|73.36|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|130|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|73.36|146.73|33.75
32073565|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC KNEES BOTH STANDING ANTEROPOSTERIOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|146.73|146.73|33.75
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|AARP [1000]|AARP [100000]|328||||328|130|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|328||||328|74.1|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|AETNA [1015]|AETNA [101529]|328||||328|34.87|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|328||||328|27.06|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|328||||328|73.36|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|328||||328|73.36|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|328||||328|154.16|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|328||||328|75.79|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|328||||328|164|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|328||||328|206.64|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|328||||328|27.06|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|328||||328|73.36|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|328||||328|39.72|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|328||||328|226.32|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|328||||328|101.13|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|328||||328|78.57|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|328||||328|34.87|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|328||||328|27.06|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|328||||328|73.36|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|328||||328|34.87|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|328||||328|27.06|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|328||||328|27.06|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|328||||328|226.32|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|328||||328|27.06|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|Self-pay|Self-pay|328||||328|114.8|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|328||||328|27.06|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|328||||328|27.06|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|328||||328|130|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|328||||328|73.36|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|328||||328|73.36|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|328||||328|130|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|328||||328|73.36|226.32|27.06
32073590|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TIBIA & FIBULA 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|328||||328|146.73|226.32|27.06
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|AARP [1000]|AARP [100000]|235||||235|130|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|235||||235|74.1|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|235||||235|34.32|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|235||||235|60.8|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|235||||235|73.36|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|235||||235|73.36|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|235||||235|110.45|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|235||||235|75.79|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|235||||235|117.5|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|235||||235|148.05|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|235||||235|60.8|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|235||||235|73.36|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|235||||235|39.18|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|235||||235|162.15|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|235||||235|101.13|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|235||||235|78.57|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|235||||235|34.32|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|235||||235|60.8|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|235||||235|73.36|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|235||||235|34.32|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|235||||235|60.8|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|235||||235|60.8|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|235||||235|162.15|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|235||||235|60.8|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|Self-pay|Self-pay|235||||235|82.25|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|235||||235|60.8|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|235||||235|60.8|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|235||||235|130|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|235||||235|73.36|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|235||||235|73.36|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|235||||235|130|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|235||||235|73.36|162.15|34.32
32073592|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC LOWER EXTREM INFANT 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|235||||235|146.73|162.15|34.32
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|AARP [1000]|AARP [100000]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|AETNA [1015]|AETNA [101529]|271||||271|35.98|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|271||||271|28.06|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|271||||271|127.37|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|271||||271|75.79|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|271||||271|135.5|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|271||||271|170.73|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|271||||271|28.06|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|271||||271|38.65|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|271||||271|186.99|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|271||||271|101.13|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|271||||271|35.98|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|271||||271|28.06|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|271||||271|35.98|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|271||||271|28.06|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|271||||271|28.06|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|271||||271|186.99|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|271||||271|28.06|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|Self-pay|Self-pay|271||||271|94.85|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|271||||271|28.06|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|271||||271|28.06|186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|271||||271||186.99|28.06
32073600|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|271||||271||186.99|28.06
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|AARP [1000]|AARP [100000]|216||||216|130|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216|74.1|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|40.44|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|29.74|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216|73.36|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216|73.36|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|75.79|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|29.74|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216|73.36|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|43.48|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|101.13|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216|78.57|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|40.44|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|29.74|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216|73.36|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|40.44|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|29.74|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|29.74|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|29.74|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|Self-pay|Self-pay|216||||216|75.6|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|29.74|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|29.74|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216|130|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216|73.36|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216|73.36|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216|130|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216|73.36|149.04|29.74
32073610|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ANKLE COMPLETE 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216|146.73|149.04|29.74
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|AARP [1000]|AARP [100000]|204||||204|130|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|74.1|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|AETNA [1015]|AETNA [101529]|204||||204|30.96|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|24.73|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|73.36|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|73.36|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|24.73|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|73.36|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|38.1|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|78.57|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|30.96|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|24.73|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|73.36|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|30.96|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|24.73|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|24.73|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|24.73|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|Self-pay|Self-pay|204||||204|71.4|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|24.73|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|24.73|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|130|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|73.36|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|73.36|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|130|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|73.36|146.73|24.73
32073620|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|146.73|146.73|24.73
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|AARP [1000]|AARP [100000]|299||||299|130|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|299||||299|74.1|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|299||||299|37.66|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|299||||299|27.74|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|299||||299|73.36|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|299||||299|73.36|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|299||||299|140.53|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|299||||299|75.79|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|299||||299|149.5|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|299||||299|188.37|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|299||||299|27.74|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|299||||299|73.36|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|299||||299|43.48|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|299||||299|206.31|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|299||||299|101.13|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|299||||299|78.57|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|299||||299|37.66|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|299||||299|27.74|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|299||||299|73.36|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|299||||299|37.66|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|299||||299|27.74|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|299||||299|27.74|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|299||||299|206.31|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|299||||299|27.74|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|Self-pay|Self-pay|299||||299|104.65|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|299||||299|27.74|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|299||||299|27.74|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|299||||299|130|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|299||||299|73.36|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|299||||299|73.36|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|299||||299|130|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|299||||299|73.36|206.31|27.74
32073630|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOOT COMPLETE 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|299||||299|146.73|206.31|27.74
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|AARP [1000]|AARP [100000]|297||||297|130|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|297||||297|74.1|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|297||||297|30.96|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|297||||297|25.73|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|297||||297|73.36|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|297||||297|73.36|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|297||||297|139.59|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|297||||297|75.79|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|297||||297|148.5|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|297||||297|187.11|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|297||||297|25.73|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|297||||297|73.36|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|297||||297|37.57|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|297||||297|204.93|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|297||||297|101.13|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|297||||297|78.57|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|297||||297|30.96|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|297||||297|25.73|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|297||||297|73.36|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|297||||297|30.96|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|297||||297|25.73|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|297||||297|25.73|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|297||||297|204.93|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|297||||297|25.73|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|Self-pay|Self-pay|297||||297|103.95|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|297||||297|25.73|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|297||||297|25.73|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|297||||297|130|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|297||||297|73.36|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|297||||297|73.36|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|297||||297|130|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|297||||297|73.36|204.93|25.73
32073650|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CALCANEUS 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|297||||297|146.73|204.93|25.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|AARP [1000]|AARP [100000]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|AETNA [1015]|AETNA [101529]|304||||304|33.19|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|304||||304|26.73|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|304||||304|142.88|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|304||||304|75.79|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|304||||304|152|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|304||||304|191.52|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|304||||304|26.73|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|304||||304|37.07|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|304||||304|209.76|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|304||||304|101.13|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|304||||304|33.19|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|304||||304|26.73|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|304||||304|33.19|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|304||||304|26.73|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|304||||304|26.73|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|304||||304|209.76|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|304||||304|26.73|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|Self-pay|Self-pay|304||||304|106.4|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|304||||304|26.73|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|304||||304|26.73|209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|304||||304||209.76|26.73
32073660|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC TOE(S) 2+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|304||||304||209.76|26.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AARP [1000]|AARP [100000]|204||||204|130|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204|74.1|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AETNA [1015]|AETNA [101529]|204||||204|30.96|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|25.73|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204|73.36|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204|73.36|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|25.73|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204|73.36|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|112.2|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204|78.57|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|30.96|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|25.73|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204|73.36|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|30.96|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|25.73|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|25.73|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|25.73|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|Self-pay|Self-pay|204||||204|71.4|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|25.73|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|25.73|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204|130|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204|73.36|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204|73.36|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204|130|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204|73.36|146.73|25.73
32074018|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 1 VIEW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204|146.73|146.73|25.73
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|AARP [1000]|AARP [100000]|216||||216|130|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216|99.8|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|AETNA [1015]|AETNA [101529]|216||||216|37.66|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|31.41|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216|98.82|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216|98.82|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216|101.52|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216|139.64|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216|108|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216|136.08|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|31.41|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216|98.82|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216|118.8|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|149.04|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|136.21|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216|105.83|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|37.66|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|31.41|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216|98.82|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|37.66|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|31.41|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|31.41|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|149.04|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|31.41|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|Self-pay|Self-pay|216||||216|75.6|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|31.41|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|31.41|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216|130|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216|98.82|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216|98.82|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216|130|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216|98.82|197.63|31.41
32074019|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216|197.63|197.63|31.41
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|AARP [1000]|AARP [100000]|299||||299|130|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|299||||299|99.8|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|299||||299|43.78|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|299||||299|36.75|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|299||||299|98.82|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|299||||299|98.82|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|299||||299|140.53|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|299||||299|139.64|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|299||||299|149.5|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|299||||299|188.37|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|299||||299|36.75|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|299||||299|98.82|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|299||||299|164.45|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|299||||299|206.31|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|299||||299|136.21|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|299||||299|105.83|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|299||||299|43.78|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|299||||299|36.75|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|299||||299|98.82|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|299||||299|43.78|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|299||||299|36.75|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|299||||299|36.75|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|299||||299|206.31|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|299||||299|36.75|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|Self-pay|Self-pay|299||||299|104.65|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|299||||299|36.75|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|299||||299|36.75|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|299||||299|130|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|299||||299|98.82|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|299||||299|98.82|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|299||||299|130|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|299||||299|98.82|206.31|36.75
32074021|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|299||||299|197.63|206.31|36.75
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|AARP [1000]|AARP [100000]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|AETNA [1015]|AETNA [101529]|442||||442|50.45|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|442||||442|42.1|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|BCBS [1155]|BCBS UTHCT [115568]|442||||442|207.74|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|442||||442|139.64|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|442||||442|221|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|442||||442|278.46|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|442||||442|42.1|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|CIGNA [1260]|CIGNA GWH [126023]|442||||442|67.06|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|GROUP PENSION ADMIN [1450]|GPA [145000]|442||||442|304.98|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|442||||442|136.21|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|442||||442|50.45|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|442||||442|42.1|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|442||||442|50.45|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|442||||442|42.1|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|442||||442|42.1|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|PHCS [1780]|PHCS MULTIPLAN [178000]|442||||442|304.98|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|442||||442|42.1|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|Self-pay|Self-pay|442||||442|154.7|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|442||||442|42.1|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|442||||442|42.1|304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|442||||442||304.98|42.1
32074022|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABDOMEN 2+V & CHEST 1V|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|442||||442||304.98|42.1
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|AARP [1000]|AARP [100000]|465||||465|130|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|465||||465|163.53|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|AETNA [1015]|AETNA [101529]|465||||465|103.32|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|465||||465|83.54|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|465||||465|161.91|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|465||||465|161.91|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|BCBS [1155]|BCBS UTHCT [115568]|465||||465|218.55|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|465||||465|308.34|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|465||||465|232.5|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|465||||465|292.95|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|465||||465|83.54|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|465||||465|161.91|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|CIGNA [1260]|CIGNA GWH [126023]|465||||465|116.47|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|465||||465|320.85|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|465||||465|223.19|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|465||||465|173.41|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|465||||465|103.32|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|465||||465|83.54|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|465||||465|161.91|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|465||||465|103.32|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|465||||465|83.54|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|465||||465|83.54|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|465||||465|320.85|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|465||||465|83.54|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|Self-pay|Self-pay|465||||465|162.75|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|465||||465|83.54|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|465||||465|83.54|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|465||||465|130|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|465||||465|161.91|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|465||||465|161.91|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|465||||465|130|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|465||||465|161.91|323.83|83.54
32074220|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ESOPHAGUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|465||||465|323.83|323.83|83.54
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AARP [1000]|AARP [100000]|592||||592|130|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|592||||592|163.53|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AETNA [1015]|AETNA [101529]|592||||592|160.66|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|592||||592|114.46|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|592||||592|161.91|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|592||||592|161.91|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS [1155]|BCBS UTHCT [115568]|592||||592|278.24|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|592||||592|139.64|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|592||||592|296|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|592||||592|372.96|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|592||||592|114.46|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|592||||592|161.91|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|CIGNA [1260]|CIGNA GWH [126023]|592||||592|122.33|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|GROUP PENSION ADMIN [1450]|GPA [145000]|592||||592|408.48|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|592||||592|223.19|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|592||||592|173.41|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|592||||592|160.66|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|592||||592|114.46|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|592||||592|161.91|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|592||||592|160.66|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|592||||592|114.46|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|592||||592|114.46|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|PHCS [1780]|PHCS MULTIPLAN [178000]|592||||592|408.48|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|592||||592|114.46|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|Self-pay|Self-pay|592||||592|207.2|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|592||||592|114.46|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|592||||592|114.46|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|592||||592|130|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|592||||592|161.91|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|592||||592|161.91|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|592||||592|130|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|592||||592|161.91|408.48|114.46
32074230|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SWALLOW FUNC W/CINE/VID MODIF C+|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|592||||592|323.83|408.48|114.46
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|AARP [1000]|AARP [100000]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|AETNA [1015]|AETNA [101529]|270||||270|124.49|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|270||||270|106.59|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|BCBS [1155]|BCBS UTHCT [115568]|270||||270|126.9|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|270||||270|270|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|270||||270|135|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|270||||270|170.1|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|270||||270|106.59|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|CIGNA [1260]|CIGNA GWH [126023]|270||||270|145.88|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|270||||270|186.3|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|270||||270|223.19|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|270||||270|124.49|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|270||||270|106.59|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|270||||270|124.49|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|270||||270|106.59|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|270||||270|106.59|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|270||||270|186.3|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|270||||270|106.59|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|Self-pay|Self-pay|270||||270|94.5|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|270||||270|106.59|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|270||||270|106.59|270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|270||||270||270|94.5
32074240|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI W/O KUB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|270||||270||270|94.5
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AARP [1000]|AARP [100000]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AETNA [1015]|AETNA [101529]|782||||782|145.63|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|782||||782|119.29|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS [1155]|BCBS UTHCT [115568]|782||||782|367.54|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|782||||782|308.34|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|782||||782|391|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|782||||782|492.66|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|782||||782|119.29|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|CIGNA [1260]|CIGNA GWH [126023]|782||||782|165.31|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|782||||782|539.58|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|782||||782|223.19|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|782||||782|145.63|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|782||||782|119.29|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|782||||782|145.63|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|782||||782|119.29|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|782||||782|119.29|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|782||||782|539.58|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|782||||782|119.29|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|Self-pay|Self-pay|782||||782|273.7|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|782||||782|119.29|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|782||||782|119.29|539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|782||||782||539.58|119.29
32074246|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UGI DOUBLE CONTRAST STUDY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|782||||782||539.58|119.29
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AARP [1000]|AARP [100000]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AETNA [1015]|AETNA [101529]|517||||517|74.02|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|517||||517|77.51|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS [1155]|BCBS UTHCT [115568]|517||||517|242.99|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|517||||517|58.23|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|517||||517|258.5|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|517||||517|325.71|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|517||||517|77.51|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|CIGNA [1260]|CIGNA GWH [126023]|517||||517|284.35|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|517||||517|356.73|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|517||||517|258.5|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|517||||517|74.02|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|517||||517|77.51|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|517||||517|74.02|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|517||||517|77.51|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|517||||517|77.51|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|517||||517|356.73|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|517||||517|77.51|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|Self-pay|Self-pay|517||||517|180.95|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|517||||517|77.51|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|517||||517|77.51|356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|517||||517||356.73|58.23
32074248|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|517||||517||356.73|58.23
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|AARP [1000]|AARP [100000]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|AETNA [1015]|AETNA [101529]|609||||609|125.04|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|609||||609|97.56|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|BCBS [1155]|BCBS UTHCT [115568]|609||||609|286.23|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|609||||609|139.64|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|609||||609|304.5|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|609||||609|383.67|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|609||||609|97.56|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|CIGNA [1260]|CIGNA GWH [126023]|609||||609|132.64|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|609||||609|420.21|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|609||||609|223.19|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|609||||609|125.04|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|609||||609|97.56|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|609||||609|125.04|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|609||||609|97.56|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|609||||609|97.56|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|609||||609|420.21|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|609||||609|97.56|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|Self-pay|Self-pay|609||||609|213.15|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|609||||609|97.56|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|609||||609|97.56|420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|609||||609||420.21|97.56
32074250|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SM BOWEL SINGLE CNTRST STD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|609||||609||420.21|97.56
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|AARP [1000]|AARP [100000]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|AETNA [1015]|AETNA [101529]|747||||747|159.55|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|747||||747|141.68|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|BCBS [1155]|BCBS UTHCT [115568]|747||||747|351.09|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|747||||747|308.34|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|747||||747|373.5|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|747||||747|470.61|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|747||||747|141.68|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|CIGNA [1260]|CIGNA GWH [126023]|747||||747|188.48|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|747||||747|515.43|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|747||||747|223.19|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|747||||747|159.55|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|747||||747|141.68|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|747||||747|159.55|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|747||||747|141.68|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|747||||747|141.68|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|747||||747|515.43|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|747||||747|141.68|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|Self-pay|Self-pay|747||||747|261.45|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|747||||747|141.68|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|747||||747|141.68|515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|747||||747||515.43|141.68
32074270|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|747||||747||515.43|141.68
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|AARP [1000]|AARP [100000]|858||||858|130|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|858||||858|163.53|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|AETNA [1015]|AETNA [101529]|858||||858|248.04|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|858||||858|201.15|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|858||||858|161.91|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|858||||858|161.91|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|BCBS [1155]|BCBS UTHCT [115568]|858||||858|403.26|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|858||||858|201.85|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|858||||858|429|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|858||||858|540.54|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|858||||858|201.15|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|858||||858|161.91|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|CIGNA [1260]|CIGNA GWH [126023]|858||||858|257.11|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|858||||858|592.02|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|858||||858|223.19|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|858||||858|173.41|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|858||||858|248.04|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|858||||858|201.15|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|858||||858|161.91|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|858||||858|248.04|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|858||||858|201.15|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|858||||858|201.15|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|858||||858|592.02|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|858||||858|201.15|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|Self-pay|Self-pay|858||||858|300.3|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|858||||858|201.15|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|858||||858|201.15|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|858||||858|130|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|858||||858|161.91|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|858||||858|161.91|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|858||||858|130|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|858||||858|161.91|592.02|130
32074280|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC COLON BARIUM ENEMA W/AIR CONT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|858||||858|323.83|592.02|130
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|AARP [1000]|AARP [100000]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|AETNA [1015]|AETNA [101529]|901||||901|161.76|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|901||||901|103.58|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|BCBS [1155]|BCBS UTHCT [115568]|901||||901|423.47|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|901||||901|105.08|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|901||||901|450.5|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|901||||901|567.63|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|901||||901|103.58|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|CIGNA [1260]|CIGNA GWH [126023]|901||||901|149.39|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|901||||901|621.69|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|901||||901|223.19|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|901||||901|161.76|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|901||||901|103.58|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|901||||901|161.76|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|901||||901|103.58|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|901||||901|103.58|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|901||||901|621.69|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|901||||901|103.58|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|Self-pay|Self-pay|901||||901|315.35|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|901||||901|103.58|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|901||||901|103.58|621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|901||||901||621.69|103.58
32074400|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM INTRAVENOUS (IVP)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|901||||901||621.69|103.58
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|AARP [1000]|AARP [100000]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|AETNA [1015]|AETNA [101529]|517||||517|199.61|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|517||||517|128.64|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|BCBS [1155]|BCBS UTHCT [115568]|517||||517|242.99|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|517||||517|137.92|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|517||||517|258.5|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|517||||517|325.71|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|517||||517|128.64|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|CIGNA [1260]|CIGNA GWH [126023]|517||||517|180.08|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|517||||517|356.73|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|517||||517|223.19|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|517||||517|199.61|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|517||||517|128.64|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|517||||517|199.61|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|517||||517|128.64|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|517||||517|128.64|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|517||||517|356.73|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|517||||517|128.64|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|Self-pay|Self-pay|517||||517|180.95|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|517||||517|128.64|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|517||||517|128.64|356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|517||||517||356.73|128.64
32074415|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM W/NEPHROTOMOGRAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|517||||517||356.73|128.64
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|AARP [1000]|AARP [100000]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|AETNA [1015]|AETNA [101529]|941||||941|75.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|941||||941|123.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|BCBS [1155]|BCBS UTHCT [115568]|941||||941|442.27|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|941||||941|555.19|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|941||||941|470.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|941||||941|592.83|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|941||||941|123.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|CIGNA [1260]|CIGNA GWH [126023]|941||||941|180.8|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|941||||941|649.29|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|941||||941|460.15|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|941||||941|75.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|941||||941|123.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|941||||941|75.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|941||||941|123.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|941||||941|123.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|941||||941|649.29|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|941||||941|123.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|Self-pay|Self-pay|941||||941|329.35|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|941||||941|123.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|941||||941|123.5|649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|941||||941||649.29|75.5
32074420|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC UROGRAM RETROGRADE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|941||||941||649.29|75.5
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|AARP [1000]|AARP [100000]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|AETNA [1015]|AETNA [101529]|594||||594|37.66|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594||||594|36.09|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|594||||594|279.18|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594||||594|308.34|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594||||594|297|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594||||594|374.22|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594||||594|36.09|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|594||||594|103.18|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|594||||594|409.86|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|594||||594|460.15|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594||||594|37.66|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594||||594|36.09|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594||||594|37.66|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594||||594|36.09|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|594||||594|36.09|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|594||||594|409.86|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594||||594|36.09|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|Self-pay|Self-pay|594||||594|207.9|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|594||||594|36.09|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594||||594|36.09|460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594||||594||460.15|36.09
32074430|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOGRAM 3+ VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594||||594||460.15|36.09
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|AARP [1000]|AARP [100000]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|AETNA [1015]|AETNA [101529]|675||||675|359.35|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|675||||675|75.06|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|BCBS [1155]|BCBS UTHCT [115568]|675||||675|317.25|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|675||||675|283.42|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|675||||675|337.5|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|675||||675|425.25|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|675||||675|75.06|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|CIGNA [1260]|CIGNA GWH [126023]|675||||675|107.51|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|675||||675|465.75|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|675||||675|287.66|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|675||||675|359.35|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|675||||675|75.06|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|675||||675|359.35|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|675||||675|75.06|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|675||||675|75.06|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|675||||675|465.75|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|675||||675|75.06|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|Self-pay|Self-pay|675||||675|236.25|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|675||||675|75.06|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|675||||675|75.06|465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|675||||675||465.75|75.06
32074450|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM RETRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|675||||675||465.75|75.06
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|AARP [1000]|AARP [100000]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|AETNA [1015]|AETNA [101529]|629||||629|126.7|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|629||||629|77.85|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|BCBS [1155]|BCBS UTHCT [115568]|629||||629|295.63|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|629||||629|283.42|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|629||||629|314.5|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|629||||629|396.27|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|629||||629|77.85|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|CIGNA [1260]|CIGNA GWH [126023]|629||||629|126.38|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|629||||629|434.01|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|629||||629|287.66|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|629||||629|126.7|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|629||||629|77.85|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|629||||629|126.7|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|629||||629|77.85|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|629||||629|77.85|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|629||||629|434.01|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|629||||629|77.85|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|Self-pay|Self-pay|629||||629|220.15|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|629||||629|77.85|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|629||||629|77.85|434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|629||||629||434.01|77.85
32074455|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC CYSTOURETHROGRAM VOIDING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|629||||629||434.01|77.85
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|AARP [1000]|AARP [100000]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|AETNA [1015]|AETNA [101529]|2062||||2062|113.9|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2062||||2062|87.54|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|BCBS [1155]|BCBS UTHCT [115568]|2062||||2062|969.14|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2062||||2062|2062|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2062||||2062|1031|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2062||||2062|1299.06|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2062||||2062|87.54|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|CIGNA [1260]|CIGNA GWH [126023]|2062||||2062|187.15|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2062||||2062|1422.78|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2062||||2062|2241.24|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2062||||2062|113.9|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2062||||2062|87.54|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2062||||2062|113.9|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2062||||2062|87.54|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2062||||2062|87.54|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2062||||2062|1422.78|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2062||||2062|87.54|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|Self-pay|Self-pay|2062||||2062|721.7|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2062||||2062|87.54|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2062||||2062|87.54|2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2062||||2062||2241.24|87.54
32074485|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DILATION URETER(S) OR URETHRA RS&I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2062||||2062||2241.24|87.54
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|AARP [1000]|AARP [100000]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|AETNA [1015]|AETNA [101529]|710||||710|111.12|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|710||||710|66.83|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|BCBS [1155]|BCBS UTHCT [115568]|710||||710|333.7|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|710||||710|283.42|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|710||||710|355|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|710||||710|447.3|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|710||||710|66.83|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|CIGNA [1260]|CIGNA GWH [126023]|710||||710|108.52|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|710||||710|489.9|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|710||||710|287.66|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|710||||710|111.12|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|710||||710|66.83|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|710||||710|111.12|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|710||||710|66.83|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|710||||710|66.83|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|710||||710|489.9|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|710||||710|66.83|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|Self-pay|Self-pay|710||||710|248.5|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|710||||710|66.83|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|710||||710|66.83|489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|710||||710||489.9|66.83
32074740|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC HYSTEROSALPINGOGRAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|710||||710||489.9|66.83
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|AARP [1000]|AARP [100000]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|AETNA [1015]|AETNA [101529]|1380||||1380|112.37|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1380||||1380|409.17|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|BCBS [1155]|BCBS UTHCT [115568]|1380||||1380|675|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1380||||1380|77.93|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1380||||1380|900|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1380||||1380|900|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1380||||1380|409.17|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|CIGNA [1260]|CIGNA GWH [126023]|1380||||1380|223.63|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1380||||1380|952.2|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1380||||1380|690|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1380||||1380|112.37|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1380||||1380|409.17|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1380||||1380|112.37|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1380||||1380|409.17|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1380||||1380|409.17|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1380||||1380|952.2|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1380||||1380|409.17|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|Self-pay|Self-pay|1380||||1380|483|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1380||||1380|409.17|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1380||||1380|409.17|952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1380||||1380||952.2|77.93
32075989|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC GUIDED ABSCESS DRAINAGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1380||||1380||952.2|77.93
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|AARP [1000]|AARP [100000]|426||||426|130|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|426||||426|210.77|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|AETNA [1015]|AETNA [101529]|426||||426|40.99|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|426||||426|45.11|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|426||||426|208.68|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|426||||426|208.68|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|BCBS [1155]|BCBS UTHCT [115568]|426||||426|200.22|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|426||||426|48.17|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|426||||426|213|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|426||||426|268.38|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|426||||426|45.11|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|426||||426|208.68|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|CIGNA [1260]|CIGNA GWH [126023]|426||||426|123.25|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|426||||426|293.94|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|426||||426|287.66|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|426||||426|223.5|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|426||||426|40.99|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|426||||426|45.11|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|426||||426|208.68|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|426||||426|40.99|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|426||||426|45.11|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|426||||426|45.11|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|426||||426|293.94|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|426||||426|45.11|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|Self-pay|Self-pay|426||||426|149.1|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|426||||426|45.11|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|426||||426|45.11|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|426||||426|130|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|426||||426|208.68|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|426||||426|208.68|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|426||||426|130|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|426||||426|208.68|417.37|40.99
32076000|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOROSCOPY UP TO 1 HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|426||||426|417.37|417.37|40.99
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|AARP [1000]|AARP [100000]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|AETNA [1015]|AETNA [101529]|529||||529|51.58|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|529||||529|51.79|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|BCBS [1155]|BCBS UTHCT [115568]|529||||529|248.63|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|529||||529|283.42|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|529||||529|264.5|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|529||||529|333.27|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|529||||529|51.79|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|CIGNA [1260]|CIGNA GWH [126023]|529||||529|92.16|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|529||||529|365.01|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|529||||529|603.61|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|529||||529|51.58|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|529||||529|51.79|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|529||||529|51.58|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|529||||529|51.79|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|529||||529|51.79|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|529||||529|365.01|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|529||||529|51.79|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|Self-pay|Self-pay|529||||529|185.15|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|529||||529|51.79|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|529||||529|51.79|603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|529||||529||603.61|51.58
32076080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ABSCESS/FIST/SINUS TRACT STUDY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|529||||529||603.61|51.58
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|AARP [1000]|AARP [100000]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|AETNA [1015]|AETNA [101529]|1367||||1367|42.1|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1367||||1367|16.04|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|BCBS [1155]|BCBS UTHCT [115568]|1367||||1367|642.49|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1367||||1367|593.76|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1367||||1367|683.5|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1367||||1367|861.21|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1367||||1367|16.04|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|CIGNA [1260]|CIGNA GWH [126023]|1367||||1367|30.04|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1367||||1367|943.23|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1367||||1367|603.61|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1367||||1367|42.1|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1367||||1367|16.04|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1367||||1367|42.1|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1367||||1367|16.04|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1367||||1367|16.04|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1367||||1367|943.23|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1367||||1367|16.04|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|Self-pay|Self-pay|1367||||1367|478.45|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1367||||1367|16.04|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1367||||1367|16.04|943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1367||||1367||943.23|16.04
32076098|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC SURGICAL SPECIMEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1367||||1367||943.23|16.04
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|AARP [1000]|AARP [100000]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|AETNA [1015]|AETNA [101529]|690||||690|125.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|690||||690|204.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|BCBS [1155]|BCBS UTHCT [115568]|690||||690|324.3|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|690||||690|81.87|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|690||||690|345|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|690||||690|434.7|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|690||||690|204.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|CIGNA [1260]|CIGNA GWH [126023]|690||||690|102.95|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|690||||690|476.1|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|690||||690|345|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|690||||690|125.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|690||||690|204.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|690||||690|125.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|690||||690|204.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|690||||690|204.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|690||||690|476.1|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|690||||690|204.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|Self-pay|Self-pay|690||||690|241.5|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|690||||690|204.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|690||||690|204.59|476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|690||||690||476.1|81.87
32077002|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUORO BIOPSY/ASPIRATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|690||||690||476.1|81.87
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|AARP [1000]|AARP [100000]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|AETNA [1015]|AETNA [101529]|449||||449|111.12|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|449||||449|133.13|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|BCBS [1155]|BCBS UTHCT [115568]|449||||449|211.03|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|449||||449|79.69|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|449||||449|224.5|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|449||||449|282.87|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|449||||449|133.13|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|CIGNA [1260]|CIGNA GWH [126023]|449||||449|93.22|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|449||||449|309.81|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|449||||449|224.5|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|449||||449|111.12|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|449||||449|133.13|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|449||||449|111.12|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|449||||449|133.13|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|449||||449|133.13|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|449||||449|309.81|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|449||||449|133.13|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|Self-pay|Self-pay|449||||449|157.15|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|449||||449|133.13|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|449||||449|133.13|309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|449||||449||309.81|79.69
32077003|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FLUOR GUID NDL CATH FOR SPINL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|449||||449||309.81|79.69
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|AARP [1000]|AARP [100000]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|AETNA [1015]|AETNA [101529]|848||||848|60.48|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|848||||848|55.14|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|BCBS [1155]|BCBS UTHCT [115568]|848||||848|398.56|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|848||||848|283.42|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|848||||848|424|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|848||||848|534.24|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|848||||848|55.14|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|CIGNA [1260]|CIGNA GWH [126023]|848||||848|132.91|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|848||||848|585.12|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|848||||848|287.66|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|848||||848|60.48|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|848||||848|55.14|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|848||||848|60.48|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|848||||848|55.14|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|848||||848|55.14|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|848||||848|585.12|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|848||||848|55.14|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|Self-pay|Self-pay|848||||848|296.8|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|848||||848|55.14|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|848||||848|55.14|585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|848||||848||585.12|55.14
32077053|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM SGL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|848||||848||585.12|55.14
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|AARP [1000]|AARP [100000]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|AETNA [1015]|AETNA [101529]|666||||666|79.39|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|666||||666|72.18|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|BCBS [1155]|BCBS UTHCT [115568]|666||||666|313.02|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|666||||666|283.42|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|666||||666|333|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|666||||666|419.58|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|666||||666|72.18|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|CIGNA [1260]|CIGNA GWH [126023]|666||||666|180.29|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|666||||666|459.54|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|666||||666|287.66|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|666||||666|79.39|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|666||||666|72.18|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|666||||666|79.39|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|666||||666|72.18|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|666||||666|72.18|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|666||||666|459.54|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|666||||666|72.18|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|Self-pay|Self-pay|666||||666|233.1|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|666||||666|72.18|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|666||||666|72.18|459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|666||||666||459.54|72.18
32077054|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MAMM DUCTOGRAM MULTI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|666||||666||459.54|72.18
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|AARP [1000]|AARP [100000]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|AETNA [1015]|AETNA [101529]|105||||105|24.29|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105||||105|21.71|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|BCBS [1155]|BCBS UTHCT [115568]|105||||105|49.35|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105||||105|105|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105||||105|52.5|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105||||105|66.15|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105||||105|21.71|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|CIGNA [1260]|CIGNA GWH [126023]|105||||105|33.22|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|GROUP PENSION ADMIN [1450]|GPA [145000]|105||||105|72.45|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105||||105|136.21|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105||||105|24.29|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105||||105|21.71|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105||||105|24.29|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105||||105|21.71|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|105||||105|21.71|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|PHCS [1780]|PHCS MULTIPLAN [178000]|105||||105|72.45|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105||||105|21.71|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|Self-pay|Self-pay|105||||105|36.75|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105||||105|21.71|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105||||105|21.71|136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105||||105||136.21|21.71
32077072|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE AGE STUDIES.|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105||||105||136.21|21.71
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|AARP [1000]|AARP [100000]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|AETNA [1015]|AETNA [101529]|161||||161|47.11|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|161||||161|34.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|BCBS [1155]|BCBS UTHCT [115568]|161||||161|75.67|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|161||||161|139.64|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|161||||161|80.5|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|161||||161|101.43|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|161||||161|34.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|CIGNA [1260]|CIGNA GWH [126023]|161||||161|57.96|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|161||||161|111.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|161||||161|136.21|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|161||||161|47.11|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|161||||161|34.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|161||||161|47.11|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|161||||161|34.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|161||||161|34.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|161||||161|111.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|161||||161|34.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|Self-pay|Self-pay|161||||161|56.35|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|161||||161|34.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|161||||161|34.09|139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|161||||161||139.64|34.09
32077073|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE LENGTH STUDIES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|161||||161||139.64|34.09
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|AARP [1000]|AARP [100000]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|AETNA [1015]|AETNA [101529]|892||||892|105|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|892||||892|82.53|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|BCBS [1155]|BCBS UTHCT [115568]|892||||892|419.24|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|892||||892|139.64|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|892||||892|446|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|892||||892|561.96|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|892||||892|82.53|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|CIGNA [1260]|CIGNA GWH [126023]|892||||892|136.34|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|892||||892|615.48|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|892||||892|136.21|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|892||||892|105|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|892||||892|82.53|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|892||||892|105|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|892||||892|82.53|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|892||||892|82.53|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|892||||892|615.48|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|892||||892|82.53|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|Self-pay|Self-pay|892||||892|312.2|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|892||||892|82.53|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|892||||892|82.53|615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|892||||892||615.48|82.53
32077075|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY COMP/METASTATIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|892||||892||615.48|82.53
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|AARP [1000]|AARP [100000]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|AETNA [1015]|AETNA [101529]|501||||501|106.1|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|501||||501|100.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|BCBS [1155]|BCBS UTHCT [115568]|501||||501|235.47|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|501||||501|139.64|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|501||||501|250.5|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|501||||501|315.63|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|501||||501|100.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|CIGNA [1260]|CIGNA GWH [126023]|501||||501|120.52|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|501||||501|345.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|501||||501|136.21|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|501||||501|106.1|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|501||||501|100.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|501||||501|106.1|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|501||||501|100.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|501||||501|100.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|501||||501|345.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|501||||501|100.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|Self-pay|Self-pay|501||||501|175.35|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|501||||501|100.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|501||||501|100.69|345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|501||||501||345.69|100.69
32077076|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE SURVEY INFANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|501||||501||345.69|100.69
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|AARP [1000]|AARP [100000]|506||||506|130|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|506||||506|99.8|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|AETNA [1015]|AETNA [101529]|506||||506|46.01|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|506||||506|39.76|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|506||||506|98.82|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|506||||506|98.82|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|BCBS [1155]|BCBS UTHCT [115568]|506||||506|237.82|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|506||||506|39.41|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|506||||506|253|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|506||||506|318.78|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|506||||506|39.76|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|506||||506|98.82|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|CIGNA [1260]|CIGNA GWH [126023]|506||||506|135.29|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|506||||506|349.14|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|506||||506|136.21|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|506||||506|105.83|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|506||||506|46.01|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|506||||506|39.76|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|506||||506|98.82|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|506||||506|46.01|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|506||||506|39.76|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|506||||506|39.76|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|506||||506|349.14|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|506||||506|39.76|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|Self-pay|Self-pay|506||||506|177.1|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|506||||506|39.76|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|506||||506|39.76|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|506||||506|130|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|506||||506|98.82|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|506||||506|98.82|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|506||||506|130|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|506||||506|98.82|349.14|39.41
32077080|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY DUAL HIP/SPINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|506||||506|197.63|349.14|39.41
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|AARP [1000]|AARP [100000]|253||||253|130|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|253||||253|74.1|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|AETNA [1015]|AETNA [101529]|253||||253|34.32|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|253||||253|26.73|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|253||||253|73.36|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|253||||253|73.36|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|BCBS [1155]|BCBS UTHCT [115568]|253||||253|118.91|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|253||||253|21.46|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|253||||253|126.5|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|253||||253|159.39|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|253||||253|26.73|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|253||||253|73.36|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|CIGNA [1260]|CIGNA GWH [126023]|253||||253|48.34|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|253||||253|174.57|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|253||||253|101.13|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|253||||253|78.57|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|253||||253|34.32|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|253||||253|26.73|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|253||||253|73.36|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|253||||253|34.32|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|253||||253|26.73|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|253||||253|26.73|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|253||||253|174.57|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|253||||253|26.73|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|Self-pay|Self-pay|253||||253|88.55|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|253||||253|26.73|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|253||||253|26.73|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|253||||253|130|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|253||||253|73.36|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|253||||253|73.36|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|253||||253|130|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|253||||253|73.36|174.57|21.46
32077081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BONE DENSITY PERIPHERAL SITE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|253||||253|146.73|174.57|21.46
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|AARP [1000]|AARP [100000]|270||||270|130|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|270||||270|99.8|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|AETNA [1015]|AETNA [101529]|270||||270|59.9|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|270||||270|53.8|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|270||||270|98.82|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|270||||270|98.82|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|BCBS [1155]|BCBS UTHCT [115568]|270||||270|126.9|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|270||||270|139.64|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|270||||270|135|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|270||||270|170.1|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|270||||270|53.8|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|270||||270|98.82|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|CIGNA [1260]|CIGNA GWH [126023]|270||||270|148.5|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|270||||270|186.3|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|270||||270|136.21|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|270||||270|105.83|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|270||||270|59.9|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|270||||270|53.8|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|270||||270|98.82|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|270||||270|59.9|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|270||||270|53.8|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|270||||270|53.8|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|270||||270|186.3|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|270||||270|53.8|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|Self-pay|Self-pay|270||||270|94.5|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|270||||270|53.8|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|270||||270|53.8|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|270||||270|130|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|270||||270|98.82|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|270||||270|98.82|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|270||||270|130|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|270||||270|98.82|197.63|53.8
32077085|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC DXA BONE DENSITY STUDY AXIAL SKELETON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|270||||270|197.63|197.63|53.8
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AARP [1000]|AARP [100000]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|220.26||||220.26|97.13|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|220.26||||220.26|65.31|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|220.26||||220.26|103.52|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|220.26||||220.26|110.13|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|220.26||||220.26|110.13|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|220.26||||220.26|138.76|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|220.26||||220.26|65.31|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|220.26||||220.26|121.14|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|220.26||||220.26|151.98|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|220.26||||220.26|110.13|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|220.26||||220.26|97.13|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|220.26||||220.26|65.31|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|220.26||||220.26|97.13|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|220.26||||220.26|65.31|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|220.26||||220.26|65.31|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|220.26||||220.26|151.98|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|220.26||||220.26|65.31|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|Self-pay|Self-pay|220.26||||220.26|77.09|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|220.26||||220.26|65.31|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|220.26||||220.26|65.31|151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|220.26||||220.26||151.98|65.31
3208|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOROMETHOLONE 0.1 % EYE DROPS,SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|220.26||||220.26||151.98|65.31
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|24.18||||24.18|24.18|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.18||||24.18|7.17|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|24.18||||24.18|11.36|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.18||||24.18|0|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.18||||24.18|12.09|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.18||||24.18|15.23|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.18||||24.18|7.17|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|24.18||||24.18|13.3|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|24.18||||24.18|16.68|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.18||||24.18|14.53|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.18||||24.18|24.18|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.18||||24.18|7.17|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.18||||24.18|24.18|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.18||||24.18|7.17|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.18||||24.18|7.17|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|24.18||||24.18|16.68|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.18||||24.18|7.17|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|24.18||||24.18|8.46|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.18||||24.18|7.17|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.18||||24.18|7.17|24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.18||||24.18||24.18|7.17
3215|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUPHENAZINE DECANOATE 25 MG/ML INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.18||||24.18||24.18|7.17
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|595.42||||595.42|262.58|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|595.42||||595.42|176.54|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|595.42||||595.42|279.85|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|595.42||||595.42|297.71|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|595.42||||595.42|297.71|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|595.42||||595.42|375.11|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|595.42||||595.42|176.54|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|595.42||||595.42|327.48|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|595.42||||595.42|410.84|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|595.42||||595.42|297.71|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|595.42||||595.42|262.58|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|595.42||||595.42|176.54|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|595.42||||595.42|262.58|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|595.42||||595.42|176.54|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|595.42||||595.42|176.54|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|595.42||||595.42|410.84|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|595.42||||595.42|176.54|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|595.42||||595.42|208.4|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|595.42||||595.42|176.54|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|595.42||||595.42|176.54|410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|595.42||||595.42||410.84|176.54
3216|ERX|0250 - PHARMACY-GENERAL|FLUPHENAZINE 2.5 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|595.42||||595.42||410.84|176.54
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|AARP [1000]|AARP [100000]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|AETNA [1015]|AETNA [101529]|14.75||||14.75|6.5|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|14.75||||14.75|6.93|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.75||||14.75|7.38|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.75||||14.75|7.38|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.75||||14.75|9.29|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|14.75||||14.75|8.11|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.75||||14.75|10.18|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.75||||14.75|7.38|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.75||||14.75|6.5|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.75||||14.75|6.5|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.75||||14.75|10.18|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|Self-pay|Self-pay|14.75||||14.75|5.16|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|AARP [1000]|AARP [100000]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|AETNA [1015]|AETNA [101529]|14.75||||14.75|6.5|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|14.75||||14.75|6.93|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.75||||14.75|7.38|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.75||||14.75|7.38|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.75||||14.75|9.29|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|14.75||||14.75|8.11|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.75||||14.75|10.18|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.75||||14.75|7.38|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.75||||14.75|6.5|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.75||||14.75|6.5|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.75||||14.75|10.18|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|Self-pay|Self-pay|14.75||||14.75|5.16|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.75||||14.75|4.37|10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.75||||14.75||10.18|4.37
3217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG/ML ORAL CONCENTRATE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.75||||14.75||10.18|4.37
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.5||||1.5|0.66|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.5||||1.5|0.44|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.5||||1.5|0.71|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.5||||1.5|0.75|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.5||||1.5|0.75|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.5||||1.5|0.95|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.5||||1.5|0.44|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.5||||1.5|0.83|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.5||||1.5|1.04|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.5||||1.5|0.75|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.5||||1.5|0.66|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.5||||1.5|0.44|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.5||||1.5|0.66|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.5||||1.5|0.44|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.5||||1.5|0.44|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.5||||1.5|1.04|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.5||||1.5|0.44|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|Self-pay|Self-pay|1.5||||1.5|0.52|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.5||||1.5|0.44|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.5||||1.5|0.44|1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.5||||1.5||1.04|0.44
3218|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.5||||1.5||1.04|0.44
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.27||||12.27|5.41|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.27||||12.27|3.64|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|12.27||||12.27|5.77|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.27||||12.27|6.14|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.27||||12.27|6.14|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.27||||12.27|7.73|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.27||||12.27|3.64|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|12.27||||12.27|6.75|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.27||||12.27|8.47|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.27||||12.27|6.14|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.27||||12.27|5.41|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.27||||12.27|3.64|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.27||||12.27|5.41|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.27||||12.27|3.64|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.27||||12.27|3.64|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.27||||12.27|8.47|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.27||||12.27|3.64|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|12.27||||12.27|4.29|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.27||||12.27|3.64|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.27||||12.27|3.64|8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.27||||12.27||8.47|3.64
3219|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.27||||12.27||8.47|3.64
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.74||||9.74|4.3|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.74||||9.74|2.89|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|9.74||||9.74|4.58|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.74||||9.74|4.87|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.74||||9.74|4.87|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.74||||9.74|6.14|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.74||||9.74|2.89|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|9.74||||9.74|5.36|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.74||||9.74|6.72|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.74||||9.74|4.87|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.74||||9.74|4.3|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.74||||9.74|2.89|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.74||||9.74|4.3|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.74||||9.74|2.89|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.74||||9.74|2.89|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.74||||9.74|6.72|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.74||||9.74|2.89|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|9.74||||9.74|3.41|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.74||||9.74|2.89|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.74||||9.74|2.89|6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.74||||9.74||6.72|2.89
3221|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUPHENAZINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.74||||9.74||6.72|2.89
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|AARP [1000]|AARP [100000]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|AETNA [1015]|AETNA [101529]|886||||886|145.08|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|886||||886|95.56|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|BCBS [1155]|BCBS UTHCT [115568]|886||||886|416.42|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|886||||886|556.77|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|886||||886|443|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|886||||886|558.18|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|886||||886|95.56|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|CIGNA [1260]|CIGNA GWH [126023]|886||||886|155.26|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|886||||886|611.34|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|886||||886|460.15|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|886||||886|145.08|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|886||||886|95.56|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|886||||886|145.08|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|886||||886|95.56|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|886||||886|95.56|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|886||||886|611.34|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|886||||886|95.56|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|Self-pay|Self-pay|886||||886|310.1|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|886||||886|95.56|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|886||||886|95.56|611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|886||||886||611.34|95.56
32273040|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC ARTHROGRAM SHOULDER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|886||||886||611.34|95.56
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|AARP [1000]|AARP [100000]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|AETNA [1015]|AETNA [101529]|433||||433|33.74|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|433||||433|33.75|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|433||||433|203.51|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|433||||433|75.79|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|433||||433|216.5|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|433||||433|272.79|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|433||||433|33.75|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|433||||433|51.55|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|433||||433|298.77|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|433||||433|101.13|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|433||||433|33.74|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|433||||433|33.75|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|433||||433|33.74|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|433||||433|33.75|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|433||||433|33.75|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|433||||433|298.77|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|433||||433|33.75|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|Self-pay|Self-pay|433||||433|151.55|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|433||||433|33.75|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|433||||433|33.75|298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|433||||433||298.77|33.74
32273050|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC ACROMIOCLAVICULAR JOINTS BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|433||||433||298.77|33.74
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AARP [1000]|AARP [100000]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AETNA [1015]|AETNA [101529]|204||||204|31.54|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|204||||204|24.39|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS [1155]|BCBS UTHCT [115568]|204||||204|95.88|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|204||||204|75.79|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|204||||204|102|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|204||||204|128.52|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|204||||204|24.39|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|CIGNA [1260]|CIGNA GWH [126023]|204||||204|39.18|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|204||||204|140.76|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|204||||204|101.13|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|204||||204|31.54|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|204||||204|24.39|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|204||||204|31.54|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|204||||204|24.39|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|204||||204|24.39|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|204||||204|140.76|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|204||||204|24.39|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|Self-pay|Self-pay|204||||204|71.4|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|204||||204|24.39|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|204||||204|24.39|140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|204||||204||140.76|24.39
32273090|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC FOREARM 2 VIEWS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|204||||204||140.76|24.39
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|AARP [1000]|AARP [100000]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|AETNA [1015]|AETNA [101529]|901||||901|167.88|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|901||||901|110.6|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|BCBS [1155]|BCBS UTHCT [115568]|901||||901|423.47|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|901||||901|556.77|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|901||||901|450.5|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|901||||901|567.63|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|901||||901|110.6|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|CIGNA [1260]|CIGNA GWH [126023]|901||||901|179.02|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|901||||901|621.69|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|901||||901|460.15|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|901||||901|167.88|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|901||||901|110.6|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|901||||901|167.88|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|901||||901|110.6|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|901||||901|110.6|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|901||||901|621.69|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|901||||901|110.6|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|Self-pay|Self-pay|901||||901|315.35|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|901||||901|110.6|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|901||||901|110.6|621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|901||||901||621.69|110.6
32273580|EAP|0322 - RADIOLOGY-DIAGNOSTIC-ARTHROGRAPHY|HC KNEE ARTHROGRAPHY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|901||||901||621.69|110.6
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.48||||0.48|0.21|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.48||||0.48|0.14|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.48||||0.48|0.23|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.48||||0.48|0.24|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.48||||0.48|0.24|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.48||||0.48|0.3|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.48||||0.48|0.14|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.48||||0.48|0.26|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.48||||0.48|0.33|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.48||||0.48|0.24|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.48||||0.48|0.21|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.48||||0.48|0.14|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.48||||0.48|0.21|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.48||||0.48|0.14|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.48||||0.48|0.14|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.48||||0.48|0.33|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.48||||0.48|0.14|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.48||||0.48|0.17|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.48||||0.48|0.14|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.48||||0.48|0.14|0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.48||||0.48||0.33|0.14
3233|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FOLIC ACID 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.48||||0.48||0.33|0.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|AARP [1000]|AARP [100000]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|AETNA [1015]|AETNA [101529]|1908||||1908|116.14|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1908||||1908|128.31|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|BCBS [1155]|BCBS UTHCT [115568]|1908||||1908|896.76|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1908||||1908|1199.22|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1908||||1908|954|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1908||||1908|1202.04|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1908||||1908|128.31|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|CIGNA [1260]|CIGNA GWH [126023]|1908||||1908|190.74|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1908||||1908|1316.52|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1908||||1908|1757.68|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1908||||1908|116.14|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1908||||1908|128.31|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1908||||1908|116.14|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1908||||1908|128.31|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1908||||1908|128.31|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1908||||1908|1316.52|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1908||||1908|128.31|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|Self-pay|Self-pay|1908||||1908|667.8|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1908||||1908|128.31|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1908||||1908|128.31|1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1908||||1908||1757.68|116.14
32375822|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC VENOGRAM EXTREMITY BILATERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1908||||1908||1757.68|116.14
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AARP [1000]|AARP [100000]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AETNA [1015]|AETNA [101529]|5794||||5794|110.02|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5794||||5794|127.3|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS [1155]|BCBS UTHCT [115568]|5794||||5794|2723.18|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5794||||5794|3041.14|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5794||||5794|2897|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5794||||5794|3650.22|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5794||||5794|127.3|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|CIGNA [1260]|CIGNA GWH [126023]|5794||||5794|521.4|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5794||||5794|3997.86|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5794||||5794|3577.08|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5794||||5794|110.02|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5794||||5794|127.3|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5794||||5794|110.02|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5794||||5794|127.3|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5794||||5794|127.3|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5794||||5794|3997.86|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5794||||5794|127.3|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|Self-pay|Self-pay|5794||||5794|2027.9|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5794||||5794|127.3|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5794||||5794|127.3|3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5794||||5794||3997.86|110.02
32375825|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOCAVAGRAM INFERIOR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5794||||5794||3997.86|110.02
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|AARP [1000]|AARP [100000]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|AETNA [1015]|AETNA [101529]|1449||||1449|127.82|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1449||||1449|136.33|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|BCBS [1155]|BCBS UTHCT [115568]|1449||||1449|681.03|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1449||||1449|1449|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1449||||1449|724.5|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1449||||1449|912.87|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1449||||1449|136.33|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|CIGNA [1260]|CIGNA GWH [126023]|1449||||1449|532.64|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1449||||1449|999.81|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1449||||1449|3577.08|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1449||||1449|127.82|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1449||||1449|136.33|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1449||||1449|127.82|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1449||||1449|136.33|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1449||||1449|136.33|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1449||||1449|999.81|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1449||||1449|136.33|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|Self-pay|Self-pay|1449||||1449|507.15|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1449||||1449|136.33|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1449||||1449|136.33|3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1449||||1449||3577.08|127.82
32375860|EAP|0323 - RADIOLOGY-DIAGNOSTIC-ARTERIOGRAPHY|HC VENOGRAM SINUS/JUGULAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1449||||1449||3577.08|127.82
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|83.7||||83.7|30.31|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83.7||||83.7|24.82|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|83.7||||83.7|39.34|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83.7||||83.7|0|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83.7||||83.7|41.85|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83.7||||83.7|52.73|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83.7||||83.7|24.82|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|83.7||||83.7|46.04|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|83.7||||83.7|57.75|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|83.7||||83.7|13.38|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83.7||||83.7|30.31|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83.7||||83.7|24.82|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83.7||||83.7|30.31|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83.7||||83.7|24.82|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|83.7||||83.7|24.82|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|83.7||||83.7|57.75|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83.7||||83.7|24.82|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|83.7||||83.7|29.29|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|83.7||||83.7|24.82|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83.7||||83.7|24.82|57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83.7||||83.7||57.75|13.38
32589|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 30 MG/10 ML (3 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83.7||||83.7||57.75|13.38
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|3.46||||3.46|1.53|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.46||||3.46|1.03|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.46||||3.46|1.63|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.46||||3.46|1.73|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.46||||3.46|1.73|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.46||||3.46|2.18|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.46||||3.46|1.03|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.46||||3.46|1.9|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.46||||3.46|2.39|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.46||||3.46|1.73|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.46||||3.46|1.53|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.46||||3.46|1.03|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.46||||3.46|1.53|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.46||||3.46|1.03|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.46||||3.46|1.03|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.46||||3.46|2.39|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.46||||3.46|1.03|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|3.46||||3.46|1.21|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.46||||3.46|1.03|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.46||||3.46|1.03|2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.46||||3.46||2.39|1.03
32631|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.46||||3.46||2.39|1.03
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|3.61||||3.61|1.59|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.61||||3.61|1.07|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.61||||3.61|1.7|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.61||||3.61|1.81|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.61||||3.61|1.81|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.61||||3.61|2.27|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.61||||3.61|1.07|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.61||||3.61|1.99|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.61||||3.61|2.49|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.61||||3.61|1.81|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.61||||3.61|1.59|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.61||||3.61|1.07|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.61||||3.61|1.59|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.61||||3.61|1.07|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.61||||3.61|1.07|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.61||||3.61|2.49|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.61||||3.61|1.07|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|3.61||||3.61|1.26|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.61||||3.61|1.07|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.61||||3.61|1.07|2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.61||||3.61||2.49|1.07
32632|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PAROXETINE ER 25 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.61||||3.61||2.49|1.07
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|AARP [1000]|AARP [100000]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|AETNA [1015]|AETNA [101529]|1928.2||||1928.2|1464|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1928.2||||1928.2|571.71|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|BCBS [1155]|BCBS UTHCT [115568]|1928.2||||1928.2|906.25|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1928.2||||1928.2|0|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1928.2||||1928.2|964.1|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1928.2||||1928.2|1214.77|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1928.2||||1928.2|571.71|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|CIGNA [1260]|CIGNA GWH [126023]|1928.2||||1928.2|964.1|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|1928.2||||1928.2|1330.46|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1928.2||||1928.2|7.58|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1928.2||||1928.2|1464|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1928.2||||1928.2|571.71|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1928.2||||1928.2|1464|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1928.2||||1928.2|571.71|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|1928.2||||1928.2|571.71|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|1928.2||||1928.2|1330.46|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1928.2||||1928.2|571.71|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|Self-pay|Self-pay|1928.2||||1928.2|674.87|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1928.2||||1928.2|571.71|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1928.2||||1928.2|571.71|1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1928.2||||1928.2||1464|7.58
32700|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA 100 UNIT SOLUTION FOR INJECTION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1928.2||||1928.2||1464|7.58
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|111.7||||111.7|90.94|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111.7||||111.7|33.12|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|111.7||||111.7|52.5|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111.7||||111.7|0|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111.7||||111.7|55.85|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111.7||||111.7|70.37|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111.7||||111.7|33.12|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|111.7||||111.7|61.44|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|111.7||||111.7|77.07|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|111.7||||111.7|13.38|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111.7||||111.7|90.94|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111.7||||111.7|33.12|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111.7||||111.7|90.94|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111.7||||111.7|33.12|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|111.7||||111.7|33.12|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|111.7||||111.7|77.07|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111.7||||111.7|33.12|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|111.7||||111.7|39.09|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|111.7||||111.7|33.12|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111.7||||111.7|33.12|90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111.7||||111.7||90.94|13.38
32855|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PAMIDRONATE 90 MG/10 ML (9 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111.7||||111.7||90.94|13.38
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|12.84||||12.84|2.6|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|12.84||||12.84|2.6|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|12.84||||12.84|2.6|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|12.84||||12.84|1.44|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|12.84||||12.84|1.44|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|12.84||||12.84|1.44|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|12.84||||12.84|6.03|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|12.84||||12.84|6.03|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|12.84||||12.84|6.03|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.84||||12.84|0|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.84||||12.84|0|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.84||||12.84|0|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.84||||12.84|6.42|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.84||||12.84|6.42|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.84||||12.84|6.42|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.84||||12.84|8.09|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.84||||12.84|8.09|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.84||||12.84|8.09|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|12.84||||12.84|7.06|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|12.84||||12.84|7.06|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|12.84||||12.84|7.06|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.84||||12.84|8.86|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.84||||12.84|8.86|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.84||||12.84|8.86|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.84||||12.84|0.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.84||||12.84|0.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.84||||12.84|0.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.84||||12.84|1.44|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.84||||12.84|1.44|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.84||||12.84|1.44|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.84||||12.84|1.44|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.84||||12.84|1.44|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.84||||12.84|1.44|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.84||||12.84|8.86|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.84||||12.84|8.86|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.84||||12.84|8.86|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|12.84||||12.84|4.49|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|12.84||||12.84|4.49|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|12.84||||12.84|4.49|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.84||||12.84|3.81|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.84||||12.84|2.6|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.84||||12.84|2.6|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.84||||12.84|2.6|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.84||||12.84|2.6|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.84||||12.84|2.6|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.84||||12.84|2.6|8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.84||||12.84||8.86|0.81
3291|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.84||||12.84||8.86|0.81
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|1.2||||1.2|0.53|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.2||||1.2|0.36|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1.2||||1.2|0.56|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.2||||1.2|0.6|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.2||||1.2|0.6|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.2||||1.2|0.76|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.2||||1.2|0.36|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1.2||||1.2|0.66|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.2||||1.2|0.83|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.2||||1.2|0.6|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.2||||1.2|0.53|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.2||||1.2|0.36|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.2||||1.2|0.53|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.2||||1.2|0.36|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.2||||1.2|0.36|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.2||||1.2|0.83|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.2||||1.2|0.36|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|1.2||||1.2|0.42|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.2||||1.2|0.36|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.2||||1.2|0.36|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.2||||1.2||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|AARP [1000]|AARP [100000]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|119.35||||119.35|52.63|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|119.35||||119.35|35.39|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|BCBS [1155]|BCBS UTHCT [115568]|119.35||||119.35|56.09|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|119.35||||119.35|59.68|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|119.35||||119.35|59.68|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|119.35||||119.35|75.19|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|119.35||||119.35|35.39|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|CIGNA [1260]|CIGNA GWH [126023]|119.35||||119.35|65.64|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|119.35||||119.35|82.35|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|119.35||||119.35|59.68|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|119.35||||119.35|52.63|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|119.35||||119.35|35.39|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|119.35||||119.35|52.63|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|119.35||||119.35|35.39|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|119.35||||119.35|35.39|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|119.35||||119.35|82.35|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|119.35||||119.35|35.39|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|Self-pay|Self-pay|119.35||||119.35|41.77|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|119.35||||119.35|35.39|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|119.35||||119.35|35.39|82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|119.35||||119.35||82.35|0.36
3293|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG/5 ML (8 MG/ML) ORAL SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|119.35||||119.35||82.35|0.36
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.21||||0.21|0.09|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.21||||0.21|0.06|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.21||||0.21|0.1|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.21||||0.21|0.11|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.21||||0.21|0.11|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.21||||0.21|0.13|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.21||||0.21|0.06|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.21||||0.21|0.12|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.21||||0.21|0.14|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.21||||0.21|0.11|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.21||||0.21|0.09|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.21||||0.21|0.06|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.21||||0.21|0.09|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.21||||0.21|0.06|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.21||||0.21|0.06|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.21||||0.21|0.14|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.21||||0.21|0.06|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.21||||0.21|0.07|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.21||||0.21|0.06|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.21||||0.21|0.06|0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.21||||0.21||0.14|0.06
3294|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.21||||0.21||0.14|0.06
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.15||||0.15|0.07|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.15||||0.15|0.04|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.15||||0.15|0.07|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.15||||0.15|0.08|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.15||||0.15|0.08|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.15||||0.15|0.09|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.15||||0.15|0.04|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.15||||0.15|0.08|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.15||||0.15|0.1|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.15||||0.15|0.08|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.15||||0.15|0.07|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.15||||0.15|0.04|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.15||||0.15|0.07|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.15||||0.15|0.04|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.15||||0.15|0.04|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.15||||0.15|0.1|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.15||||0.15|0.04|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|Self-pay|Self-pay|0.15||||0.15|0.05|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.15||||0.15|0.04|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.15||||0.15|0.04|0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.15||||0.15||0.1|0.04
3295|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.15||||0.15||0.1|0.04
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AARP [1000]|AARP [100000]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AETNA [1015]|AETNA [101529]|52.9||||52.9|23.33|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52.9||||52.9|15.68|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BCBS UTHCT [115568]|52.9||||52.9|24.86|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52.9||||52.9|26.45|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52.9||||52.9|26.45|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52.9||||52.9|33.33|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52.9||||52.9|15.68|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|CIGNA [1260]|CIGNA GWH [126023]|52.9||||52.9|29.1|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|52.9||||52.9|36.5|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|52.9||||52.9|26.45|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52.9||||52.9|23.33|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52.9||||52.9|15.68|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52.9||||52.9|23.33|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52.9||||52.9|15.68|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|52.9||||52.9|15.68|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|52.9||||52.9|36.5|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52.9||||52.9|15.68|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|Self-pay|Self-pay|52.9||||52.9|18.51|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|52.9||||52.9|15.68|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52.9||||52.9|15.68|36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52.9||||52.9||36.5|15.68
33008|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VORICONAZOLE 50 MG TABLET|2 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52.9||||52.9||36.5|15.68
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AARP [1000]|AARP [100000]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AETNA [1015]|AETNA [101529]|227.05||||227.05|71.52|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|227.05||||227.05|67.32|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|BCBS [1155]|BCBS UTHCT [115568]|227.05||||227.05|106.71|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|227.05||||227.05|0|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|227.05||||227.05|113.53|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|227.05||||227.05|143.04|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|227.05||||227.05|67.32|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|CIGNA [1260]|CIGNA GWH [126023]|227.05||||227.05|124.88|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|227.05||||227.05|156.66|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|227.05||||227.05|2.06|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|227.05||||227.05|71.52|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|227.05||||227.05|67.32|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|227.05||||227.05|71.52|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|227.05||||227.05|67.32|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|227.05||||227.05|67.32|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|227.05||||227.05|156.66|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|227.05||||227.05|67.32|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|Self-pay|Self-pay|227.05||||227.05|79.47|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|227.05||||227.05|67.32|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|227.05||||227.05|67.32|156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|227.05||||227.05||156.66|2.06
33010|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VORICONAZOLE 200 MG INTRAVENOUS SOLUTION|200 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|227.05||||227.05||156.66|2.06
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AARP [1000]|AARP [100000]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|1.91||||1.91|0.84|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.91||||1.91|0.57|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.91||||1.91|0.9|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.91||||1.91|0.96|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.91||||1.91|0.96|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.91||||1.91|1.2|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.91||||1.91|0.57|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.91||||1.91|1.05|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.91||||1.91|1.32|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.91||||1.91|0.96|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.91||||1.91|0.84|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.91||||1.91|0.57|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.91||||1.91|0.84|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.91||||1.91|0.57|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.91||||1.91|0.57|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.91||||1.91|1.32|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.91||||1.91|0.57|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|Self-pay|Self-pay|1.91||||1.91|0.67|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.91||||1.91|0.57|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.91||||1.91|0.57|1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.91||||1.91||1.32|0.57
33108|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL SR 200 MG TABLET,12 HR SUSTAINED-RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.91||||1.91||1.32|0.57
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AARP [1000]|AARP [100000]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AETNA [1015]|AETNA [101529]|169.48||||169.48|82.66|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|169.48||||169.48|50.25|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS [1155]|BCBS UTHCT [115568]|169.48||||169.48|79.66|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|169.48||||169.48|0|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|169.48||||169.48|84.74|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|169.48||||169.48|106.77|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|169.48||||169.48|50.25|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|CIGNA [1260]|CIGNA GWH [126023]|169.48||||169.48|93.21|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|169.48||||169.48|116.94|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|169.48||||169.48|26.19|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|169.48||||169.48|82.66|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|169.48||||169.48|50.25|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|169.48||||169.48|82.66|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|169.48||||169.48|50.25|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|169.48||||169.48|50.25|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|169.48||||169.48|116.94|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|169.48||||169.48|50.25|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|Self-pay|Self-pay|169.48||||169.48|59.32|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|169.48||||169.48|50.25|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|169.48||||169.48|50.25|116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|169.48||||169.48||116.94|26.19
33175|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZIPRASIDONE 20 MG/ML (FINAL CONCENTRATION) INTRAMUSCULAR SOLUTION|20 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|169.48||||169.48||116.94|26.19
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|AARP [1000]|AARP [100000]|191||||191|79.81|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|191||||191|62.76|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|AETNA [1015]|AETNA [101529]|191||||191|85.01|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|191||||191|52.2|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|191||||191|62.14|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|191||||191|62.14|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|BCBS [1155]|BCBS UTHCT [115568]|191||||191|89.77|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|191||||191|87.63|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|191||||191|95.5|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|191||||191|120.33|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|191||||191|52.2|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|191||||191|62.14|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|CIGNA [1260]|CIGNA GWH [126023]|191||||191|105.05|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|191||||191|131.79|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|191||||191|77.68|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|191||||191|62.14|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|191||||191|85.01|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|191||||191|52.2|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|191||||191|62.14|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|191||||191|85.01|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|191||||191|52.2|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|191||||191|52.2|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|191||||191|131.79|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|191||||191|52.2|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|Self-pay|Self-pay|191||||191|66.85|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|191||||191|52.2|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|191||||191|52.2|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|191||||191|79.81|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|191||||191|62.14|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|191||||191|62.14|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|191||||191|79.81|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|191||||191|62.14|131.79|52.2
33180307|EAP|0301 - LABORATORY-CHEMISTRY|HC DRUG SCREEN SINGLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|191||||191|124.28|131.79|52.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|AARP [1000]|AARP [100000]|248||||248|248|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|248||||248|56.76|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|AETNA [1015]|AETNA [101529]|248||||248|114.77|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|248||||248|73.53|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|248||||248|56.2|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|248||||248|56.2|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|BCBS [1155]|BCBS UTHCT [115568]|248||||248|116.56|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|248||||248|71|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|248||||248|124|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|248||||248|156.24|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|248||||248|73.53|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|248||||248|56.2|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|CIGNA [1260]|CIGNA GWH [126023]|248||||248|248|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|248||||248|171.12|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|248||||248|77.46|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|248||||248|60.19|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|248||||248|114.77|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|248||||248|73.53|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|248||||248|56.2|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|248||||248|114.77|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|248||||248|73.53|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|248||||248|73.53|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|248||||248|171.12|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|248||||248|73.53|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|Self-pay|Self-pay|248||||248|86.8|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|248||||248|73.53|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|248||||248|73.53|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|248||||248|248|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|248||||248|56.2|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|248||||248|56.2|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|248||||248|248|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|248||||248|56.2|248|56.2
33196401|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM NON-HORM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|248||||248|112.4|248|56.2
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|AARP [1000]|AARP [100000]|213.82||||213.82|213.82|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|213.82||||213.82|56.76|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|AETNA [1015]|AETNA [101529]|213.82||||213.82|46.01|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|213.82||||213.82|63.4|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|213.82||||213.82|56.2|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|213.82||||213.82|56.2|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|BCBS [1155]|BCBS UTHCT [115568]|213.82||||213.82|100.5|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|213.82||||213.82|71|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|213.82||||213.82|106.91|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|213.82||||213.82|134.71|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|213.82||||213.82|63.4|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|213.82||||213.82|56.2|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|CIGNA [1260]|CIGNA GWH [126023]|213.82||||213.82|213.82|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|213.82||||213.82|147.54|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|213.82||||213.82|77.46|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|213.82||||213.82|60.19|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|213.82||||213.82|46.01|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|213.82||||213.82|63.4|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|213.82||||213.82|56.2|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|213.82||||213.82|46.01|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|213.82||||213.82|63.4|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|213.82||||213.82|63.4|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|213.82||||213.82|147.54|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|213.82||||213.82|63.4|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|Self-pay|Self-pay|213.82||||213.82|74.84|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|213.82||||213.82|63.4|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|213.82||||213.82|63.4|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|213.82||||213.82|213.82|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|213.82||||213.82|56.2|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|213.82||||213.82|56.2|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|213.82||||213.82|213.82|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|213.82||||213.82|56.2|213.82|46.01
33196402|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO SUBQ/IM HORMONAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|213.82||||213.82|112.4|213.82|46.01
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|AARP [1000]|AARP [100000]|669.83||||669.83|405|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|669.83||||669.83|186.38|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|AETNA [1015]|AETNA [101529]|669.83||||669.83|295.4|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|669.83||||669.83|198.6|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|669.83||||669.83|184.54|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|669.83||||669.83|184.54|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|BCBS [1155]|BCBS UTHCT [115568]|669.83||||669.83|314.82|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|669.83||||669.83|135.73|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|669.83||||669.83|334.92|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|669.83||||669.83|421.99|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|669.83||||669.83|198.6|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|669.83||||669.83|184.54|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|CIGNA [1260]|CIGNA GWH [126023]|669.83||||669.83|405|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|669.83||||669.83|462.18|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|669.83||||669.83|254.38|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|669.83||||669.83|197.64|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|669.83||||669.83|295.4|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|669.83||||669.83|198.6|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|669.83||||669.83|184.54|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|669.83||||669.83|295.4|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|669.83||||669.83|198.6|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|669.83||||669.83|198.6|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|669.83||||669.83|462.18|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|669.83||||669.83|198.6|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|Self-pay|Self-pay|669.83||||669.83|234.44|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|669.83||||669.83|198.6|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|669.83||||669.83|198.6|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|669.83||||669.83|405|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|669.83||||669.83|184.54|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|669.83||||669.83|184.54|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|669.83||||669.83|405|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|669.83||||669.83|184.54|462.18|135.73
33196409|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH SGL OR INITIAL DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|669.83||||669.83|369.07|462.18|135.73
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|AARP [1000]|AARP [100000]|278||||278|278|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|278||||278|56.76|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|AETNA [1015]|AETNA [101529]|278||||278|85.58|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|278||||278|82.43|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|278||||278|56.2|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|278||||278|56.2|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|BCBS [1155]|BCBS UTHCT [115568]|278||||278|130.66|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|278||||278|72.69|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|278||||278|139|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|278||||278|175.14|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|278||||278|82.43|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|278||||278|56.2|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|CIGNA [1260]|CIGNA GWH [126023]|278||||278|278|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|278||||278|191.82|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|278||||278|77.46|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|278||||278|60.19|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|278||||278|85.58|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|278||||278|82.43|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|278||||278|56.2|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|278||||278|85.58|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|278||||278|82.43|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|278||||278|82.43|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|278||||278|191.82|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|278||||278|82.43|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|Self-pay|Self-pay|278||||278|97.3|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|278||||278|82.43|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|278||||278|82.43|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|278||||278|278|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|278||||278|56.2|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|278||||278|56.2|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|278||||278|278|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|278||||278|56.2|278|56.2
33196411|EAP|0331 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV PUSH ADDL DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|278||||278|112.4|278|56.2
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.49||||1.49|0.66|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.49||||1.49|0.44|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.49||||1.49|0.7|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.49||||1.49|0.75|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.49||||1.49|0.75|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.49||||1.49|0.94|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.49||||1.49|0.44|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.49||||1.49|0.82|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.49||||1.49|1.03|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.49||||1.49|0.75|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.49||||1.49|0.66|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.49||||1.49|0.44|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.49||||1.49|0.66|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.49||||1.49|0.44|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.49||||1.49|0.44|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.49||||1.49|1.03|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.49||||1.49|0.44|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|Self-pay|Self-pay|1.49||||1.49|0.52|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.49||||1.49|0.44|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.49||||1.49|0.44|1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.49||||1.49||1.03|0.44
33228|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.49||||1.49||1.03|0.44
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|AARP [1000]|AARP [100000]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|AETNA [1015]|AETNA [101529]|45.26||||45.26|19.96|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45.26||||45.26|13.42|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|45.26||||45.26|21.27|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45.26||||45.26|22.63|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45.26||||45.26|22.63|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45.26||||45.26|28.51|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45.26||||45.26|13.42|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|45.26||||45.26|24.89|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|45.26||||45.26|31.23|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|45.26||||45.26|22.63|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45.26||||45.26|19.96|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45.26||||45.26|13.42|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45.26||||45.26|19.96|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45.26||||45.26|13.42|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|45.26||||45.26|13.42|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|45.26||||45.26|31.23|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45.26||||45.26|13.42|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|Self-pay|Self-pay|45.26||||45.26|15.84|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|45.26||||45.26|13.42|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45.26||||45.26|13.42|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45.26||||45.26||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|8.03||||8.03|3.54|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.03||||8.03|2.38|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|8.03||||8.03|3.77|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.03||||8.03|4.02|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.03||||8.03|4.02|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.03||||8.03|5.06|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.03||||8.03|2.38|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|8.03||||8.03|4.42|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.03||||8.03|5.54|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.03||||8.03|4.02|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.03||||8.03|3.54|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.03||||8.03|2.38|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.03||||8.03|3.54|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.03||||8.03|2.38|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.03||||8.03|2.38|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.03||||8.03|5.54|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.03||||8.03|2.38|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|8.03||||8.03|2.81|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.03||||8.03|2.38|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.03||||8.03|2.38|31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.03||||8.03||31.23|2.38
33230|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.03||||8.03||31.23|2.38
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|AARP [1000]|AARP [100000]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|AETNA [1015]|AETNA [101529]|963||||963|137.81|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|963||||963|285.53|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|BCBS [1155]|BCBS UTHCT [115568]|963||||963|675|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|963||||963|93.7|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|963||||963|900|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|963||||963|900|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|963||||963|285.53|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|CIGNA [1260]|CIGNA GWH [126023]|963||||963|400|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|963||||963|664.47|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|963||||963|481.5|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|963||||963|137.81|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|963||||963|285.53|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|963||||963|137.81|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|963||||963|285.53|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|963||||963|285.53|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|963||||963|664.47|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|963||||963|285.53|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|Self-pay|Self-pay|963||||963|337.05|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|963||||963|285.53|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|963||||963|285.53|900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|963||||963||900|93.7
33377014|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE RADIATION THERAPY FLDS PLACEMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|963||||963||900|93.7
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|AARP [1000]|AARP [100000]|308||||308|308|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|308||||308|116.2|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|AETNA [1015]|AETNA [101529]|308||||308|308|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|308||||308|91.32|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|308||||308|115.05|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|308||||308|115.05|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|BCBS [1155]|BCBS UTHCT [115568]|308||||308|144.76|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|308||||308|303.87|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|308||||308|154|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|308||||308|194.04|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|308||||308|91.32|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|308||||308|115.05|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|CIGNA [1260]|CIGNA GWH [126023]|308||||308|308|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|308||||308|212.52|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|308||||308|158.59|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|308||||308|123.22|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|308||||308|308|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|308||||308|91.32|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|308||||308|115.05|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|308||||308|308|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|308||||308|91.32|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|308||||308|91.32|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|308||||308|212.52|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|308||||308|91.32|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|Self-pay|Self-pay|308||||308|107.8|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|308||||308|91.32|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|308||||308|91.32|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|308||||308|308|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|308||||308|115.05|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|308||||308|115.05|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|308||||308|308|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|308||||308|115.05|308|91.32
33377280|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|308||||308|230.1|308|91.32
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|AARP [1000]|AARP [100000]|1529||||1529|400|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1529||||1529|310.19|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|AETNA [1015]|AETNA [101529]|1529||||1529|714.02|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1529||||1529|453.35|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1529||||1529|307.12|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1529||||1529|307.12|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|BCBS [1155]|BCBS UTHCT [115568]|1529||||1529|718.63|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1529||||1529|553.43|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1529||||1529|764.5|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1529||||1529|963.27|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1529||||1529|453.35|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1529||||1529|307.12|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|CIGNA [1260]|CIGNA GWH [126023]|1529||||1529|400|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1529||||1529|1055.01|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1529||||1529|423.35|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1529||||1529|328.93|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1529||||1529|714.02|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1529||||1529|453.35|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1529||||1529|307.12|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1529||||1529|714.02|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1529||||1529|453.35|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1529||||1529|453.35|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1529||||1529|1055.01|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1529||||1529|453.35|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|Self-pay|Self-pay|1529||||1529|535.15|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1529||||1529|453.35|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1529||||1529|453.35|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1529||||1529|400|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1529||||1529|307.12|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1529||||1529|307.12|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1529||||1529|400|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1529||||1529|307.12|1055.01|307.12
33377290|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SIMULATION COMPLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1529||||1529|614.25|1055.01|307.12
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|AARP [1000]|AARP [100000]|457||||457|400|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|457||||457||457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|AETNA [1015]|AETNA [101529]|457||||457|457|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|457||||457|135.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|457||||457||457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|457||||457||457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|BCBS [1155]|BCBS UTHCT [115568]|457||||457|214.79|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|457||||457|457|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|457||||457|228.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|457||||457|287.91|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|457||||457|135.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|457||||457||457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|CIGNA [1260]|CIGNA GWH [126023]|457||||457|400|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|457||||457|315.33|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|457||||457|228.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|457||||457||457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|457||||457|457|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|457||||457|135.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|457||||457||457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|457||||457|457|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|457||||457|135.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|457||||457|135.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|457||||457|315.33|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|457||||457|135.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|Self-pay|Self-pay|457||||457|159.95|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|457||||457|135.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|457||||457|135.5|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|457||||457|400|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|457||||457||457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|457||||457||457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|457||||457|400|457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|457||||457||457|135.5
33377293|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC RESPIRATOR MOTION MGMT SIMUL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|457||||457||457|135.5
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|AARP [1000]|AARP [100000]|3573||||3573|400|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3573||||3573|1156.02|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|AETNA [1015]|AETNA [101529]|3573||||3573|447.36|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3573||||3573|1059.39|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3573||||3573|1144.57|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3573||||3573|1144.57|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|BCBS [1155]|BCBS UTHCT [115568]|3573||||3573|1679.31|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3573||||3573|341.08|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3573||||3573|1786.5|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3573||||3573|2250.99|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3573||||3573|1059.39|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3573||||3573|1144.57|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|CIGNA [1260]|CIGNA GWH [126023]|3573||||3573|400|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3573||||3573|2465.37|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3573||||3573|1577.73|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3573||||3573|1225.84|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3573||||3573|447.36|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3573||||3573|1059.39|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3573||||3573|1144.57|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3573||||3573|447.36|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3573||||3573|1059.39|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3573||||3573|1059.39|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3573||||3573|2465.37|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3573||||3573|1059.39|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|Self-pay|Self-pay|3573||||3573|1250.55|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3573||||3573|1059.39|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3573||||3573|1059.39|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3573||||3573|400|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3573||||3573|1144.57|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3573||||3573|1144.57|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3573||||3573|400|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3573||||3573|1144.57|2465.37|341.08
33377295|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC 3-D RADIOTHERAPY PLAN INC DVH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3573||||3573|2289.14|2465.37|341.08
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|AARP [1000]|AARP [100000]|340||||340|340|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|340||||340|116.2|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|AETNA [1015]|AETNA [101529]|340||||340|57.7|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|340||||340|100.81|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|340||||340|115.05|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|340||||340|115.05|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|BCBS [1155]|BCBS UTHCT [115568]|340||||340|159.8|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|340||||340|43.35|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|340||||340|170|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|340||||340|214.2|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|340||||340|100.81|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|340||||340|115.05|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|CIGNA [1260]|CIGNA GWH [126023]|340||||340|340|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|340||||340|234.6|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|340||||340|158.59|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|340||||340|123.22|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|340||||340|57.7|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|340||||340|100.81|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|340||||340|115.05|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|340||||340|57.7|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|340||||340|100.81|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|340||||340|100.81|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|340||||340|234.6|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|340||||340|100.81|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|Self-pay|Self-pay|340||||340|119|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|340||||340|100.81|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|340||||340|100.81|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|340||||340|340|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|340||||340|115.05|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|340||||340|115.05|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|340||||340|340|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|340||||340|115.05|340|43.35
33377300|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DOSIMETRY BASIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|340||||340|230.1|340|43.35
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|AARP [1000]|AARP [100000]|2822||||2822|400|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2822||||2822|1156.02|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|AETNA [1015]|AETNA [101529]|2822||||2822|2555.45|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2822||||2822|836.72|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2822||||2822|1144.57|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2822||||2822|1144.57|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|BCBS [1155]|BCBS UTHCT [115568]|2822||||2822|1326.34|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2822||||2822|1955.84|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2822||||2822|1411|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2822||||2822|1777.86|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2822||||2822|836.72|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2822||||2822|1144.57|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|CIGNA [1260]|CIGNA GWH [126023]|2822||||2822|400|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2822||||2822|1947.18|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2822||||2822|1577.73|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2822||||2822|1225.84|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2822||||2822|2555.45|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2822||||2822|836.72|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2822||||2822|1144.57|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2822||||2822|2555.45|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2822||||2822|836.72|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2822||||2822|836.72|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2822||||2822|1947.18|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2822||||2822|836.72|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|Self-pay|Self-pay|2822||||2822|987.7|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2822||||2822|836.72|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2822||||2822|836.72|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2822||||2822|400|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2822||||2822|1144.57|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2822||||2822|1144.57|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2822||||2822|400|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2822||||2822|1144.57|2555.45|400
33377301|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC INTENS MOD RADTX (IMRT) PLAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2822||||2822|2289.14|2555.45|400
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|AARP [1000]|AARP [100000]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|AETNA [1015]|AETNA [101529]|307||||307|128.81|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|307||||307|91.03|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|BCBS [1155]|BCBS UTHCT [115568]|307||||307|144.29|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|307||||307|97.64|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|307||||307|153.5|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|307||||307|193.41|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|307||||307|91.03|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|CIGNA [1260]|CIGNA GWH [126023]|307||||307|307|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|GROUP PENSION ADMIN [1450]|GPA [145000]|307||||307|211.83|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|307||||307|423.35|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|307||||307|128.81|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|307||||307|91.03|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|307||||307|128.81|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|307||||307|91.03|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|307||||307|91.03|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|PHCS [1780]|PHCS MULTIPLAN [178000]|307||||307|211.83|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|307||||307|91.03|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|Self-pay|Self-pay|307||||307|107.45|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|307||||307|91.03|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|307||||307|91.03|423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|307||||307||423.35|91.03
33377306|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN SIMPL 1-2|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|307||||307||423.35|91.03
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|AARP [1000]|AARP [100000]|728||||728|400|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|728||||728|310.19|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|AETNA [1015]|AETNA [101529]|728||||728|232.99|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|728||||728|215.85|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|728||||728|307.12|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|728||||728|307.12|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|BCBS [1155]|BCBS UTHCT [115568]|728||||728|342.16|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|728||||728|176.45|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|728||||728|364|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|728||||728|458.64|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|728||||728|215.85|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|728||||728|307.12|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|CIGNA [1260]|CIGNA GWH [126023]|728||||728|400|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|728||||728|502.32|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|728||||728|423.35|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|728||||728|328.93|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|728||||728|232.99|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|728||||728|215.85|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|728||||728|307.12|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|728||||728|232.99|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|728||||728|215.85|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|728||||728|215.85|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|728||||728|502.32|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|728||||728|215.85|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|Self-pay|Self-pay|728||||728|254.8|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|728||||728|215.85|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|728||||728|215.85|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|728||||728|400|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|728||||728|307.12|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|728||||728|307.12|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|728||||728|400|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|728||||728|307.12|614.25|176.45
33377307|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TELETHX ISODOSE PLAN CPLX MULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|728||||728|614.25|614.25|176.45
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|AARP [1000]|AARP [100000]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|AETNA [1015]|AETNA [101529]|586||||586|40.01|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|586||||586|173.75|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|BCBS [1155]|BCBS UTHCT [115568]|586||||586|275.42|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|586||||586|43.79|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|586||||586|293|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|586||||586|369.18|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|586||||586|173.75|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|CIGNA [1260]|CIGNA GWH [126023]|586||||586|400|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|586||||586|404.34|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|586||||586|158.59|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|586||||586|40.01|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|586||||586|173.75|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|586||||586|40.01|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|586||||586|173.75|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|586||||586|173.75|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|586||||586|404.34|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|586||||586|173.75|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|Self-pay|Self-pay|586||||586|205.1|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|586||||586|173.75|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|586||||586|173.75|404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|586||||586||404.34|40.01
33377332|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|586||||586||404.34|40.01
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|AARP [1000]|AARP [100000]|781||||781|400|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|781||||781|116.2|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|AETNA [1015]|AETNA [101529]|781||||781|138.77|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|781||||781|231.57|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|781||||781|115.05|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|781||||781|115.05|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|BCBS [1155]|BCBS UTHCT [115568]|781||||781|367.07|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|781||||781|73.55|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|781||||781|390.5|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|781||||781|492.03|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|781||||781|231.57|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|781||||781|115.05|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|CIGNA [1260]|CIGNA GWH [126023]|781||||781|400|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|781||||781|538.89|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|781||||781|158.59|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|781||||781|123.22|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|781||||781|138.77|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|781||||781|231.57|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|781||||781|115.05|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|781||||781|138.77|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|781||||781|231.57|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|781||||781|231.57|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|781||||781|538.89|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|781||||781|231.57|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|Self-pay|Self-pay|781||||781|273.35|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|781||||781|231.57|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|781||||781|231.57|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|781||||781|400|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|781||||781|115.05|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|781||||781|115.05|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|781||||781|400|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|781||||781|115.05|538.89|73.55
33377333|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE INTERMEDIATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|781||||781|230.1|538.89|73.55
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|AARP [1000]|AARP [100000]|976||||976|400|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|976||||976|310.19|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|AETNA [1015]|AETNA [101529]|976||||976|113.78|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|976||||976|289.38|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|976||||976|307.12|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|976||||976|307.12|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|BCBS [1155]|BCBS UTHCT [115568]|976||||976|458.72|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|976||||976|86.69|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|976||||976|488|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|976||||976|614.88|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|976||||976|289.38|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|976||||976|307.12|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|CIGNA [1260]|CIGNA GWH [126023]|976||||976|400|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|976||||976|673.44|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|976||||976|423.35|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|976||||976|328.93|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|976||||976|113.78|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|976||||976|289.38|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|976||||976|307.12|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|976||||976|113.78|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|976||||976|289.38|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|976||||976|289.38|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|976||||976|673.44|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|976||||976|289.38|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|Self-pay|Self-pay|976||||976|341.6|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|976||||976|289.38|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|976||||976|289.38|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|976||||976|400|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|976||||976|307.12|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|976||||976|307.12|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|976||||976|400|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|976||||976|307.12|673.44|86.69
33377334|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC TREATMENT DEVICE COMPLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|976||||976|614.25|673.44|86.69
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|AARP [1000]|AARP [100000]|481||||481|400|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|481||||481|116.2|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|AETNA [1015]|AETNA [101529]|481||||481|135.86|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|481||||481|142.62|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|481||||481|115.05|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|481||||481|115.05|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|BCBS [1155]|BCBS UTHCT [115568]|481||||481|226.07|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|481||||481|100.7|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|481||||481|240.5|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|481||||481|303.03|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|481||||481|142.62|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|481||||481|115.05|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|CIGNA [1260]|CIGNA GWH [126023]|481||||481|400|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|481||||481|331.89|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|481||||481|158.59|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|481||||481|123.22|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|481||||481|135.86|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|481||||481|142.62|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|481||||481|115.05|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|481||||481|135.86|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|481||||481|142.62|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|481||||481|142.62|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|481||||481|331.89|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|481||||481|142.62|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|Self-pay|Self-pay|481||||481|168.35|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|481||||481|142.62|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|481||||481|142.62|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|481||||481|400|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|481||||481|115.05|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|481||||481|115.05|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|481||||481|400|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|481||||481|115.05|400|100.7
33377336|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS CONTINUING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|481||||481|230.1|400|100.7
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|AARP [1000]|AARP [100000]|2657||||2657|400|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2657||||2657|310.19|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|AETNA [1015]|AETNA [101529]|2657||||2657|445.7|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2657||||2657|787.8|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2657||||2657|307.12|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2657||||2657|307.12|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|BCBS [1155]|BCBS UTHCT [115568]|2657||||2657|1248.79|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2657||||2657|363.41|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2657||||2657|1328.5|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2657||||2657|1673.91|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2657||||2657|787.8|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2657||||2657|307.12|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|CIGNA [1260]|CIGNA GWH [126023]|2657||||2657|400|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2657||||2657|1833.33|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2657||||2657|423.35|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2657||||2657|328.93|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2657||||2657|445.7|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2657||||2657|787.8|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2657||||2657|307.12|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2657||||2657|445.7|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2657||||2657|787.8|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2657||||2657|787.8|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2657||||2657|1833.33|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2657||||2657|787.8|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|Self-pay|Self-pay|2657||||2657|929.95|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2657||||2657|787.8|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2657||||2657|787.8|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2657||||2657|400|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2657||||2657|307.12|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2657||||2657|307.12|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2657||||2657|400|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2657||||2657|307.12|1833.33|307.12
33377338|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DESIGN MLC DEVICE FOR IMRT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2657||||2657|614.25|1833.33|307.12
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|AARP [1000]|AARP [100000]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|AETNA [1015]|AETNA [101529]|550||||550|211.58|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|550||||550|163.08|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|BCBS [1155]|BCBS UTHCT [115568]|550||||550|258.5|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|550||||550|155|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|550||||550|275|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|550||||550|346.5|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|550||||550|163.08|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|CIGNA [1260]|CIGNA GWH [126023]|550||||550|400|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|550||||550|379.5|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|550||||550|158.59|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|550||||550|211.58|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|550||||550|163.08|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|550||||550|211.58|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|550||||550|163.08|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|550||||550|163.08|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|550||||550|379.5|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|550||||550|163.08|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|Self-pay|Self-pay|550||||550|192.5|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|550||||550|163.08|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|550||||550|163.08|400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|550||||550||400|155
33377370|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC MEDICAL PHYSICS SPECIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|550||||550||400|155
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|AARP [1000]|AARP [100000]|5170||||5170|400|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5170||||5170|1587.91|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|AETNA [1015]|AETNA [101529]|5170||||5170|2074.61|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5170||||5170|1532.91|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5170||||5170|1572.19|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5170||||5170|1572.19|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|BCBS [1155]|BCBS UTHCT [115568]|5170||||5170|2429.9|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5170||||5170|1730.35|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5170||||5170|2585|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5170||||5170|3257.1|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5170||||5170|1532.91|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5170||||5170|1572.19|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|CIGNA [1260]|CIGNA GWH [126023]|5170||||5170|400|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5170||||5170|3567.3|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5170||||5170|2167.18|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5170||||5170|1683.81|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5170||||5170|2074.61|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5170||||5170|1532.91|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5170||||5170|1572.19|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5170||||5170|2074.61|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5170||||5170|1532.91|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5170||||5170|1532.91|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5170||||5170|3567.3|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5170||||5170|1532.91|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|Self-pay|Self-pay|5170||||5170|1809.5|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5170||||5170|1532.91|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5170||||5170|1532.91|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5170||||5170|400|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5170||||5170|1572.19|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5170||||5170|1572.19|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5170||||5170|400|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5170||||5170|1572.19|3567.3|400
33377373|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SBRT W/IMAGE GUID PER FX 1-5 TOTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5170||||5170|3144.37|3567.3|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|AARP [1000]|AARP [100000]|1380||||1380|400|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1380||||1380|496.92|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|AETNA [1015]|AETNA [101529]|1380||||1380|622.18|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1380||||1380|409.17|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1380||||1380|492|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1380||||1380|492|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|BCBS [1155]|BCBS UTHCT [115568]|1380||||1380|648.6|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1380||||1380|637.22|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1380||||1380|690|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1380||||1380|869.4|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1380||||1380|409.17|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1380||||1380|492|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|CIGNA [1260]|CIGNA GWH [126023]|1380||||1380|400|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1380||||1380|952.2|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1380||||1380|678.19|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1380||||1380|526.93|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1380||||1380|622.18|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1380||||1380|409.17|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1380||||1380|492|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1380||||1380|622.18|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1380||||1380|409.17|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1380||||1380|409.17|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1380||||1380|952.2|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1380||||1380|409.17|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|Self-pay|Self-pay|1380||||1380|483|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1380||||1380|409.17|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1380||||1380|409.17|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1380||||1380|400|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1380||||1380|492|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1380||||1380|492|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1380||||1380|400|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1380||||1380|492|983.99|400
33377385|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK SMPL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1380||||1380|983.99|983.99|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|AARP [1000]|AARP [100000]|2070||||2070|400|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2070||||2070|496.92|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|AETNA [1015]|AETNA [101529]|2070||||2070|623.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2070||||2070|613.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2070||||2070|492|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2070||||2070|492|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|BCBS [1155]|BCBS UTHCT [115568]|2070||||2070|972.9|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2070||||2070|1252.23|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2070||||2070|1035|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2070||||2070|1304.1|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2070||||2070|613.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2070||||2070|492|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|CIGNA [1260]|CIGNA GWH [126023]|2070||||2070|400|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2070||||2070|1428.3|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2070||||2070|678.19|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2070||||2070|526.93|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2070||||2070|623.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2070||||2070|613.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2070||||2070|492|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2070||||2070|623.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2070||||2070|613.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2070||||2070|613.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2070||||2070|1428.3|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2070||||2070|613.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|Self-pay|Self-pay|2070||||2070|724.5|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2070||||2070|613.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2070||||2070|613.76|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2070||||2070|400|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2070||||2070|492|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2070||||2070|492|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2070||||2070|400|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2070||||2070|492|1428.3|400
33377386|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY IMRT W/GUIDE-TRK CPLX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2070||||2070|983.99|1428.3|400
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|AARP [1000]|AARP [100000]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|AETNA [1015]|AETNA [101529]|800||||800|119.88|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|800||||800|237.2|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|BCBS [1155]|BCBS UTHCT [115568]|800||||800|376|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|800||||800|89.32|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|800||||800|400|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|800||||800|504|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|800||||800|237.2|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|CIGNA [1260]|CIGNA GWH [126023]|800||||800|400|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|800||||800|552|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|800||||800|400|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|800||||800|119.88|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|800||||800|237.2|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|800||||800|119.88|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|800||||800|237.2|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|800||||800|237.2|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|800||||800|552|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|800||||800|237.2|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|Self-pay|Self-pay|800||||800|280|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|800||||800|237.2|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|800||||800|237.2|552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|800||||800||552|89.32
33377387|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC GUIDANCE TARGET VOL RAD TX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|800||||800||552|89.32
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|AARP [1000]|AARP [100000]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|AETNA [1015]|AETNA [101529]|272||||272|41.86|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272||||272|80.65|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|BCBS [1155]|BCBS UTHCT [115568]|272||||272|127.84|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272||||272|31.09|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272||||272|136|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272||||272|171.36|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272||||272|80.65|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|CIGNA [1260]|CIGNA GWH [126023]|272||||272|272|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|272||||272|187.68|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|272||||272|150.68|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272||||272|41.86|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272||||272|80.65|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272||||272|41.86|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272||||272|80.65|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|272||||272|80.65|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|272||||272|187.68|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272||||272|80.65|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|Self-pay|Self-pay|272||||272|95.2|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|272||||272|80.65|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272||||272|80.65|272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272||||272||272|31.09
33377401|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SUPER/ORTHO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272||||272||272|31.09
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|AARP [1000]|AARP [100000]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|AETNA [1015]|AETNA [101529]|272||||272|242.4|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272||||272|80.65|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|BCBS [1155]|BCBS UTHCT [115568]|272||||272|127.84|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272||||272|171.19|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272||||272|136|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272||||272|171.36|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272||||272|80.65|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|CIGNA [1260]|CIGNA GWH [126023]|272||||272|272|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|272||||272|187.68|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|272||||272|150.68|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272||||272|242.4|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272||||272|80.65|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272||||272|242.4|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272||||272|80.65|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|272||||272|80.65|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|272||||272|187.68|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272||||272|80.65|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|Self-pay|Self-pay|272||||272|95.2|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|272||||272|80.65|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272||||272|80.65|272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272||||272||272|80.65
33377402|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272||||272||272|80.65
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|AARP [1000]|AARP [100000]|525||||525|400|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|525||||525|221.36|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|AETNA [1015]|AETNA [101529]|525||||525|445.39|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|525||||525|155.66|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|525||||525|219.16|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|525||||525|219.16|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|BCBS [1155]|BCBS UTHCT [115568]|525||||525|246.75|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|525||||525|295.11|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|525||||525|262.5|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|525||||525|330.75|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|525||||525|155.66|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|525||||525|219.16|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|CIGNA [1260]|CIGNA GWH [126023]|525||||525|400|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|525||||525|362.25|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|525||||525|302.1|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|525||||525|234.72|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|525||||525|445.39|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|525||||525|155.66|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|525||||525|219.16|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|525||||525|445.39|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|525||||525|155.66|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|525||||525|155.66|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|525||||525|362.25|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|525||||525|155.66|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|Self-pay|Self-pay|525||||525|183.75|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|525||||525|155.66|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|525||||525|155.66|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|525||||525|400|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|525||||525|219.16|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|525||||525|219.16|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|525||||525|400|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|525||||525|219.16|445.39|155.66
33377412|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC DELIVERY >= 1 MEV COMPLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|525||||525|438.33|445.39|155.66
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|AARP [1000]|AARP [100000]|800||||800|400|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|800||||800||552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|AETNA [1015]|AETNA [101529]|800||||800|19.3|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|800||||800|237.2|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|800||||800||552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|800||||800||552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|BCBS [1155]|BCBS UTHCT [115568]|800||||800|376|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|800||||800|14.01|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|800||||800|400|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|800||||800|504|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|800||||800|237.2|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|800||||800||552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|CIGNA [1260]|CIGNA GWH [126023]|800||||800|400|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|800||||800|552|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|800||||800|400|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|800||||800||552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|800||||800|19.3|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|800||||800|237.2|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|800||||800||552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|800||||800|19.3|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|800||||800|237.2|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|800||||800|237.2|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|800||||800|552|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|800||||800|237.2|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|Self-pay|Self-pay|800||||800|280|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|800||||800|237.2|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|800||||800|237.2|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|800||||800|400|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|800||||800||552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|800||||800||552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|800||||800|400|552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|800||||800||552|14.01
33377417|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC PORT IMAGE(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|800||||800||552|14.01
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|AARP [1000]|AARP [100000]|1380||||1380|400|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1380||||1380|496.92|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|AETNA [1015]|AETNA [101529]|1380||||1380|43.68|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1380||||1380|409.17|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1380||||1380|492|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1380||||1380|492|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|BCBS [1155]|BCBS UTHCT [115568]|1380||||1380|648.6|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1380||||1380|38.97|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1380||||1380|690|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1380||||1380|869.4|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1380||||1380|409.17|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1380||||1380|492|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|CIGNA [1260]|CIGNA GWH [126023]|1380||||1380|400|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1380||||1380|952.2|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1380||||1380|678.19|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1380||||1380|526.93|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1380||||1380|43.68|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1380||||1380|409.17|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1380||||1380|492|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1380||||1380|43.68|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1380||||1380|409.17|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1380||||1380|409.17|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1380||||1380|952.2|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1380||||1380|409.17|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|Self-pay|Self-pay|1380||||1380|483|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1380||||1380|409.17|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1380||||1380|409.17|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1380||||1380|400|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1380||||1380|492|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1380||||1380|492|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1380||||1380|400|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1380||||1380|492|983.99|38.97
33377470|EAP|0333 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC SPECIAL TREATMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1380||||1380|983.99|983.99|38.97
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|AARP [1000]|AARP [100000]|502||||502|405|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|502||||502|284.62|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|AETNA [1015]|AETNA [101529]|502||||502|221.38|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|502||||502|148.84|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|502||||502|281.8|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|502||||502|281.8|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|BCBS [1155]|BCBS UTHCT [115568]|502||||502|235.94|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|502||||502|363.04|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|502||||502|251|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|502||||502|316.26|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|502||||502|148.84|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|502||||502|281.8|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|CIGNA [1260]|CIGNA GWH [126023]|502||||502|405|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|502||||502|346.38|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|502||||502|388.44|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|502||||502|301.81|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|502||||502|221.38|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|502||||502|148.84|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|502||||502|281.8|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|502||||502|221.38|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|502||||502|148.84|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|502||||502|148.84|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|502||||502|346.38|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|502||||502|148.84|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|Self-pay|Self-pay|502||||502|175.7|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|502||||502|148.84|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|502||||502|148.84|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|502||||502|405|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|502||||502|281.8|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|502||||502|281.8|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|502||||502|405|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|502||||502|281.8|563.6|148.84
33500498|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO EXTEND IV INFUS W/PUMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|502||||502|563.6|563.6|148.84
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.48||||0.48|0.21|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.48||||0.48|0.14|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.48||||0.48|0.23|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.48||||0.48|0.24|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.48||||0.48|0.24|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.48||||0.48|0.3|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.48||||0.48|0.14|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.48||||0.48|0.26|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.48||||0.48|0.33|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.48||||0.48|0.24|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.48||||0.48|0.21|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.48||||0.48|0.14|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.48||||0.48|0.21|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.48||||0.48|0.14|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.48||||0.48|0.14|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.48||||0.48|0.33|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.48||||0.48|0.14|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.48||||0.48|0.17|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.48||||0.48|0.14|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.48||||0.48|0.14|0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.48||||0.48||0.33|0.14
33512|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESCITALOPRAM 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.48||||0.48||0.33|0.14
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.48||||4.48|1.98|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.48||||4.48|1.33|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.48||||4.48|2.11|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.48||||4.48|2.24|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.48||||4.48|2.24|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.48||||4.48|2.82|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.48||||4.48|1.33|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.48||||4.48|2.46|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.48||||4.48|3.09|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.48||||4.48|2.24|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.48||||4.48|1.98|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.48||||4.48|1.33|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.48||||4.48|1.98|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.48||||4.48|1.33|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.48||||4.48|1.33|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.48||||4.48|3.09|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.48||||4.48|1.33|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|Self-pay|Self-pay|4.48||||4.48|1.57|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.48||||4.48|1.33|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.48||||4.48|1.33|3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.48||||4.48||3.09|1.33
33541|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VALSARTAN 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.48||||4.48||3.09|1.33
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|AARP [1000]|AARP [100000]|1047||||1047|405|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1047||||1047|284.62|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|AETNA [1015]|AETNA [101529]|1047||||1047|204.19|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1047||||1047|310.44|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1047||||1047|281.8|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1047||||1047|281.8|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|BCBS [1155]|BCBS UTHCT [115568]|1047||||1047|492.09|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1047||||1047|176.01|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1047||||1047|523.5|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1047||||1047|659.61|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1047||||1047|310.44|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1047||||1047|281.8|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|CIGNA [1260]|CIGNA GWH [126023]|1047||||1047|405|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1047||||1047|722.43|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1047||||1047|388.44|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1047||||1047|301.81|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1047||||1047|204.19|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1047||||1047|310.44|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1047||||1047|281.8|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1047||||1047|204.19|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1047||||1047|310.44|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1047||||1047|310.44|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1047||||1047|722.43|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1047||||1047|310.44|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|Self-pay|Self-pay|1047||||1047|366.45|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1047||||1047|310.44|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1047||||1047|310.44|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1047||||1047|405|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1047||||1047|281.8|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1047||||1047|281.8|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1047||||1047|405|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1047||||1047|281.8|722.43|176.01
33596413|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS UP TO 1HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1047||||1047|563.6|722.43|176.01
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|AARP [1000]|AARP [100000]|452||||452|405|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|452||||452|56.76|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|AETNA [1015]|AETNA [101529]|452||||452|43.92|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|452||||452|134.02|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|452||||452|56.2|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|452||||452|56.2|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|BCBS [1155]|BCBS UTHCT [115568]|452||||452|212.44|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|452||||452|38.53|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|452||||452|226|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|452||||452|284.76|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|452||||452|134.02|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|452||||452|56.2|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|CIGNA [1260]|CIGNA GWH [126023]|452||||452|405|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|452||||452|311.88|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|452||||452|77.46|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|452||||452|60.19|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|452||||452|43.92|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|452||||452|134.02|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|452||||452|56.2|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|452||||452|43.92|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|452||||452|134.02|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|452||||452|134.02|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|452||||452|311.88|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|452||||452|134.02|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|Self-pay|Self-pay|452||||452|158.2|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|452||||452|134.02|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|452||||452|134.02|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|452||||452|405|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|452||||452|56.2|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|452||||452|56.2|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|452||||452|405|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|452||||452|56.2|405|38.53
33596415|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EA ADDL HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|452||||452|112.4|405|38.53
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|AARP [1000]|AARP [100000]|1031.99||||1031.99|405|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1031.99||||1031.99|284.62|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|AETNA [1015]|AETNA [101529]|1031.99||||1031.99|204.19|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1031.99||||1031.99|305.99|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1031.99||||1031.99|281.8|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1031.99||||1031.99|281.8|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|BCBS [1155]|BCBS UTHCT [115568]|1031.99||||1031.99|485.04|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1031.99||||1031.99|179.07|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1031.99||||1031.99|516|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1031.99||||1031.99|650.15|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1031.99||||1031.99|305.99|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1031.99||||1031.99|281.8|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|CIGNA [1260]|CIGNA GWH [126023]|1031.99||||1031.99|405|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1031.99||||1031.99|712.07|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1031.99||||1031.99|388.44|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1031.99||||1031.99|301.81|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1031.99||||1031.99|204.19|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1031.99||||1031.99|305.99|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1031.99||||1031.99|281.8|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1031.99||||1031.99|204.19|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1031.99||||1031.99|305.99|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1031.99||||1031.99|305.99|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1031.99||||1031.99|712.07|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1031.99||||1031.99|305.99|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|Self-pay|Self-pay|1031.99||||1031.99|361.2|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1031.99||||1031.99|305.99|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1031.99||||1031.99|305.99|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1031.99||||1031.99|405|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1031.99||||1031.99|281.8|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1031.99||||1031.99|281.8|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1031.99||||1031.99|405|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1031.99||||1031.99|281.8|712.07|179.07
33596416|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INF >8HRS W PUMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1031.99||||1031.99|563.6|712.07|179.07
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|AARP [1000]|AARP [100000]|213.82||||213.82|213.82|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|213.82||||213.82|56.76|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|AETNA [1015]|AETNA [101529]|213.82||||213.82|99.12|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|213.82||||213.82|63.4|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|213.82||||213.82|56.2|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|213.82||||213.82|56.2|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|BCBS [1155]|BCBS UTHCT [115568]|213.82||||213.82|100.5|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|213.82||||213.82|84.51|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|213.82||||213.82|106.91|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|213.82||||213.82|134.71|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|213.82||||213.82|63.4|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|213.82||||213.82|56.2|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|CIGNA [1260]|CIGNA GWH [126023]|213.82||||213.82|213.82|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|213.82||||213.82|147.54|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|213.82||||213.82|77.46|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|213.82||||213.82|60.19|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|213.82||||213.82|99.12|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|213.82||||213.82|63.4|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|213.82||||213.82|56.2|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|213.82||||213.82|99.12|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|213.82||||213.82|63.4|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|213.82||||213.82|63.4|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|213.82||||213.82|147.54|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|213.82||||213.82|63.4|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|Self-pay|Self-pay|213.82||||213.82|74.84|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|213.82||||213.82|63.4|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|213.82||||213.82|63.4|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|213.82||||213.82|213.82|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|213.82||||213.82|56.2|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|213.82||||213.82|56.2|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|213.82||||213.82|213.82|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|213.82||||213.82|56.2|213.82|56.2
33596417|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC CHEMO IV INFUS EACH ADDL SEQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|213.82||||213.82|112.4|213.82|56.2
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|AARP [1000]|AARP [100000]|669.83||||669.83|405|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|669.83||||669.83|186.38|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|AETNA [1015]|AETNA [101529]|669.83||||669.83|213.58|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|669.83||||669.83|198.6|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|669.83||||669.83|184.54|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|669.83||||669.83|184.54|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|BCBS [1155]|BCBS UTHCT [115568]|669.83||||669.83|314.82|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|669.83||||669.83|182.59|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|669.83||||669.83|334.92|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|669.83||||669.83|421.99|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|669.83||||669.83|198.6|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|669.83||||669.83|184.54|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|CIGNA [1260]|CIGNA GWH [126023]|669.83||||669.83|405|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|669.83||||669.83|462.18|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|669.83||||669.83|254.38|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|669.83||||669.83|197.64|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|669.83||||669.83|213.58|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|669.83||||669.83|198.6|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|669.83||||669.83|184.54|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|669.83||||669.83|213.58|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|669.83||||669.83|198.6|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|669.83||||669.83|198.6|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|669.83||||669.83|462.18|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|669.83||||669.83|198.6|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|Self-pay|Self-pay|669.83||||669.83|234.44|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|669.83||||669.83|198.6|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|669.83||||669.83|198.6|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|669.83||||669.83|405|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|669.83||||669.83|184.54|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|669.83||||669.83|184.54|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|669.83||||669.83|405|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|669.83||||669.83|184.54|462.18|182.59
33596521|EAP|0335 - RADIOLOGY-THERAPEUTIC AND/OR CHEMOTHERAPY A|HC REFILL/MAINTAIN PORT PUMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|669.83||||669.83|369.07|462.18|182.59
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|AARP [1000]|AARP [100000]|4200.72||||4200.72|3242.16|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4200.72||||4200.72|421.44|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|AETNA [1015]|AETNA [101529]|4200.72||||4200.72|1482.41|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4200.72||||4200.72|1245.51|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4200.72||||4200.72|417.27|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4200.72||||4200.72|417.27|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|BCBS [1155]|BCBS UTHCT [115568]|4200.72||||4200.72|1974.34|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4200.72||||4200.72|0|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4200.72||||4200.72|2100.36|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4200.72||||4200.72|2646.45|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4200.72||||4200.72|1245.51|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4200.72||||4200.72|417.27|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|CIGNA [1260]|CIGNA GWH [126023]|4200.72||||4200.72|2100.36|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|4200.72||||4200.72|2898.5|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4200.72||||4200.72|286.16|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4200.72||||4200.72|417.27|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4200.72||||4200.72|1482.41|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4200.72||||4200.72|1245.51|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4200.72||||4200.72|417.27|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4200.72||||4200.72|1482.41|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4200.72||||4200.72|1245.51|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|4200.72||||4200.72|1245.51|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|4200.72||||4200.72|2898.5|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4200.72||||4200.72|1245.51|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|Self-pay|Self-pay|4200.72||||4200.72|1470.25|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4200.72||||4200.72|1245.51|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4200.72||||4200.72|1245.51|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4200.72||||4200.72|3242.16|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4200.72||||4200.72|417.27|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4200.72||||4200.72|417.27|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4200.72||||4200.72|3242.16|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4200.72||||4200.72|417.27|3242.16|286.16
33669|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE|22.5 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4200.72||||4200.72|834.54|3242.16|286.16
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001001|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001002|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001003|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001004|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001007|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001008|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001009|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001010|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001011|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001012|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001013|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001014|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001015|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001016|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001017|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001018|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001019|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001020|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001021|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001022|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34001023|EAP|0340 - NUCLEAR MEDICINE-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101001|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101002|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101003|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101004|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101007|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101008|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101009|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101010|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101011|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101013|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101015|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101016|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101017|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101019|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101020|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101021|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101022|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34101023|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|AARP [1000]|AARP [100000]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|AETNA [1015]|AETNA [101529]|804||||804|114.07|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|804||||804|79.19|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|BCBS [1155]|BCBS UTHCT [115568]|804||||804|377.88|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|804||||804|91.95|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|804||||804|402|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|804||||804|506.52|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|804||||804|79.19|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|CIGNA [1260]|CIGNA GWH [126023]|804||||804|650|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|804||||804|554.76|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|804||||804|471.4|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|804||||804|114.07|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|804||||804|79.19|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|804||||804|114.07|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|804||||804|79.19|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|804||||804|79.19|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|804||||804|554.76|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|804||||804|79.19|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|Self-pay|Self-pay|804||||804|281.4|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|804||||804|79.19|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|804||||804|79.19|650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|804||||804||650|79.19
34178012|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID UPTAKE SINGLE/MULTIPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|804||||804||650|79.19
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|AARP [1000]|AARP [100000]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|AETNA [1015]|AETNA [101529]|2667||||2667|342.43|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2667||||2667|236.56|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|BCBS [1155]|BCBS UTHCT [115568]|2667||||2667|1253.49|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2667||||2667|279.34|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2667||||2667|1333.5|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2667||||2667|1680.21|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2667||||2667|236.56|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|CIGNA [1260]|CIGNA GWH [126023]|2667||||2667|650|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2667||||2667|1840.23|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2667||||2667|471.4|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2667||||2667|342.43|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2667||||2667|236.56|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2667||||2667|342.43|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2667||||2667|236.56|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2667||||2667|236.56|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2667||||2667|1840.23|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2667||||2667|236.56|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|Self-pay|Self-pay|2667||||2667|933.45|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2667||||2667|236.56|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2667||||2667|236.56|1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2667||||2667||1840.23|236.56
34178014|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID IMAG W/SGL/MULT UPTAKE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2667||||2667||1840.23|236.56
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|AARP [1000]|AARP [100000]|2211||||2211|650|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2211||||2211|448.23|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|AETNA [1015]|AETNA [101529]|2211||||2211|432.6|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2211||||2211|301.73|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2211||||2211|443.79|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2211||||2211|443.79|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|BCBS [1155]|BCBS UTHCT [115568]|2211||||2211|1039.17|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2211||||2211|350.27|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2211||||2211|1105.5|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2211||||2211|1392.93|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2211||||2211|301.73|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2211||||2211|443.79|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|CIGNA [1260]|CIGNA GWH [126023]|2211||||2211|650|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2211||||2211|1525.59|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2211||||2211|611.75|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2211||||2211|475.3|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2211||||2211|432.6|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2211||||2211|301.73|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2211||||2211|443.79|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2211||||2211|432.6|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2211||||2211|301.73|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2211||||2211|301.73|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2211||||2211|1525.59|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2211||||2211|301.73|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|Self-pay|Self-pay|2211||||2211|773.85|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2211||||2211|301.73|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2211||||2211|301.73|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2211||||2211|650|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2211||||2211|443.79|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2211||||2211|443.79|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2211||||2211|650|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2211||||2211|443.79|1525.59|301.73
34178018|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC THYROID CA METS WHOLE BODY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2211||||2211|887.59|1525.59|301.73
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|AARP [1000]|AARP [100000]|1455||||1455|650|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1455||||1455|345.4|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|AETNA [1015]|AETNA [101529]|1455||||1455|409.78|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1455||||1455|287.69|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1455||||1455|341.98|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1455||||1455|341.98|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|BCBS [1155]|BCBS UTHCT [115568]|1455||||1455|683.85|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1455||||1455|336.7|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1455||||1455|727.5|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1455||||1455|916.65|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1455||||1455|287.69|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1455||||1455|341.98|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|CIGNA [1260]|CIGNA GWH [126023]|1455||||1455|650|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1455||||1455|1003.95|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1455||||1455|471.4|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1455||||1455|366.26|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1455||||1455|409.78|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1455||||1455|287.69|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1455||||1455|341.98|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1455||||1455|409.78|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1455||||1455|287.69|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1455||||1455|287.69|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1455||||1455|1003.95|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1455||||1455|287.69|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|Self-pay|Self-pay|1455||||1455|509.25|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1455||||1455|287.69|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1455||||1455|287.69|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1455||||1455|650|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1455||||1455|341.98|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1455||||1455|341.98|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1455||||1455|650|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1455||||1455|341.98|1003.95|287.69
34178070|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1455||||1455|683.95|1003.95|287.69
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|AARP [1000]|AARP [100000]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|AETNA [1015]|AETNA [101529]|1401||||1401|469.87|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1401||||1401|333.08|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|BCBS [1155]|BCBS UTHCT [115568]|1401||||1401|658.47|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1401||||1401|385.74|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1401||||1401|700.5|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1401||||1401|882.63|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1401||||1401|333.08|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|CIGNA [1260]|CIGNA GWH [126023]|1401||||1401|650|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1401||||1401|966.69|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1401||||1401|471.4|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1401||||1401|469.87|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1401||||1401|333.08|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1401||||1401|469.87|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1401||||1401|333.08|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1401||||1401|333.08|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1401||||1401|966.69|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1401||||1401|333.08|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|Self-pay|Self-pay|1401||||1401|490.35|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1401||||1401|333.08|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1401||||1401|333.08|966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1401||||1401||966.69|333.08
34178071|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PARATHYROID PLANAR W/SPECT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1401||||1401||966.69|333.08
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|AARP [1000]|AARP [100000]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|AETNA [1015]|AETNA [101529]|1338||||1338|228.72|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1338||||1338|163.39|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|1338||||1338|628.86|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1338||||1338|184.33|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1338||||1338|669|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1338||||1338|842.94|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1338||||1338|163.39|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|1338||||1338|650|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1338||||1338|923.22|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1338||||1338|471.4|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1338||||1338|228.72|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1338||||1338|163.39|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1338||||1338|228.72|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1338||||1338|163.39|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1338||||1338|163.39|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1338||||1338|923.22|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1338||||1338|163.39|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|Self-pay|Self-pay|1338||||1338|468.3|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1338||||1338|163.39|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1338||||1338|163.39|923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1338||||1338||923.22|163.39
34178102|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE MARROW LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1338||||1338||923.22|163.39
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|AARP [1000]|AARP [100000]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|AETNA [1015]|AETNA [101529]|1910||||1910|272.3|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1910||||1910|187.45|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|BCBS [1155]|BCBS UTHCT [115568]|1910||||1910|897.7|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1910||||1910|219.36|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1910||||1910|955|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1910||||1910|1203.3|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1910||||1910|187.45|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|CIGNA [1260]|CIGNA GWH [126023]|1910||||1910|650|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1910||||1910|1317.9|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1910||||1910|471.4|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1910||||1910|272.3|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1910||||1910|187.45|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1910||||1910|272.3|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1910||||1910|187.45|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1910||||1910|187.45|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1910||||1910|1317.9|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1910||||1910|187.45|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|Self-pay|Self-pay|1910||||1910|668.5|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1910||||1910|187.45|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1910||||1910|187.45|1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1910||||1910||1317.9|187.45
34178215|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC LIVER & SPLEEN STATIC ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1910||||1910||1317.9|187.45
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|AARP [1000]|AARP [100000]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|AETNA [1015]|AETNA [101529]|1017||||1017|463.75|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1017||||1017|318.09|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|1017||||1017|477.99|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1017||||1017|379.62|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1017||||1017|508.5|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1017||||1017|640.71|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1017||||1017|318.09|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|1017||||1017|650|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1017||||1017|701.73|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1017||||1017|471.4|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1017||||1017|463.75|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1017||||1017|318.09|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1017||||1017|463.75|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1017||||1017|318.09|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1017||||1017|318.09|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1017||||1017|701.73|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1017||||1017|318.09|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|Self-pay|Self-pay|1017||||1017|355.95|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1017||||1017|318.09|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1017||||1017|318.09|701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1017||||1017||701.73|318.09
34178226|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBILIARY SYSTEM IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1017||||1017||701.73|318.09
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|AARP [1000]|AARP [100000]|1991||||1991|650|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1991||||1991|448.23|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|AETNA [1015]|AETNA [101529]|1991||||1991|633.31|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1991||||1991|429.13|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1991||||1991|443.79|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1991||||1991|443.79|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|BCBS [1155]|BCBS UTHCT [115568]|1991||||1991|935.77|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1991||||1991|520.6|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1991||||1991|995.5|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1991||||1991|1254.33|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1991||||1991|429.13|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1991||||1991|443.79|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|CIGNA [1260]|CIGNA GWH [126023]|1991||||1991|650|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1991||||1991|1373.79|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1991||||1991|611.75|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1991||||1991|475.3|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1991||||1991|633.31|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1991||||1991|429.13|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1991||||1991|443.79|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1991||||1991|633.31|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1991||||1991|429.13|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1991||||1991|429.13|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1991||||1991|1373.79|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1991||||1991|429.13|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|Self-pay|Self-pay|1991||||1991|696.85|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1991||||1991|429.13|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1991||||1991|429.13|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1991||||1991|650|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1991||||1991|443.79|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1991||||1991|443.79|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1991||||1991|650|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1991||||1991|443.79|1373.79|429.13
34178227|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC HEPATOBIL SYST IMAGE W/DRUG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1991||||1991|887.59|1373.79|429.13
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|AARP [1000]|AARP [100000]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|AETNA [1015]|AETNA [101529]|1188||||1188|327.96|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1188||||1188|232.23|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|BCBS [1155]|BCBS UTHCT [115568]|1188||||1188|558.36|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1188||||1188|268.4|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1188||||1188|594|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1188||||1188|748.44|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1188||||1188|232.23|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|CIGNA [1260]|CIGNA GWH [126023]|1188||||1188|650|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1188||||1188|819.72|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1188||||1188|471.4|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1188||||1188|327.96|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1188||||1188|232.23|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1188||||1188|327.96|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1188||||1188|232.23|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1188||||1188|232.23|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1188||||1188|819.72|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1188||||1188|232.23|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|Self-pay|Self-pay|1188||||1188|415.8|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1188||||1188|232.23|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1188||||1188|232.23|819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1188||||1188||819.72|232.23
34178262|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTROESOPHAGEAL REFLUX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1188||||1188||819.72|232.23
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|AARP [1000]|AARP [100000]|1916||||1916|650|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1916||||1916|345.4|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|AETNA [1015]|AETNA [101529]|1916||||1916|467.66|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1916||||1916|322.44|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1916||||1916|341.98|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1916||||1916|341.98|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|BCBS [1155]|BCBS UTHCT [115568]|1916||||1916|900.52|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1916||||1916|383.12|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1916||||1916|958|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1916||||1916|1207.08|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1916||||1916|322.44|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1916||||1916|341.98|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|CIGNA [1260]|CIGNA GWH [126023]|1916||||1916|650|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1916||||1916|1322.04|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1916||||1916|471.4|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1916||||1916|366.26|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1916||||1916|467.66|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1916||||1916|322.44|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1916||||1916|341.98|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1916||||1916|467.66|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1916||||1916|322.44|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1916||||1916|322.44|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1916||||1916|1322.04|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1916||||1916|322.44|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|Self-pay|Self-pay|1916||||1916|670.6|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1916||||1916|322.44|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1916||||1916|322.44|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1916||||1916|650|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1916||||1916|341.98|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1916||||1916|341.98|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1916||||1916|650|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1916||||1916|341.98|1322.04|322.44
34178264|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GASTRIC EMPTYING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1916||||1916|683.95|1322.04|322.44
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AARP [1000]|AARP [100000]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AETNA [1015]|AETNA [101529]|1919||||1919|476.57|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1919||||1919|333.08|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS [1155]|BCBS UTHCT [115568]|1919||||1919|901.93|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1919||||1919|387.06|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1919||||1919|959.5|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1919||||1919|1208.97|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1919||||1919|333.08|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|CIGNA [1260]|CIGNA GWH [126023]|1919||||1919|650|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1919||||1919|1324.11|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1919||||1919|471.4|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1919||||1919|476.57|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1919||||1919|333.08|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1919||||1919|476.57|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1919||||1919|333.08|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1919||||1919|333.08|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1919||||1919|1324.11|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1919||||1919|333.08|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|Self-pay|Self-pay|1919||||1919|671.65|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1919||||1919|333.08|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1919||||1919|333.08|1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1919||||1919||1324.11|333.08
34178278|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC GI BLOOD LOSS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1919||||1919||1324.11|333.08
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|AARP [1000]|AARP [100000]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|AETNA [1015]|AETNA [101529]|1203||||1203|315.55|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1203||||1203|177.09|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|1203||||1203|565.41|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1203||||1203|257.46|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1203||||1203|601.5|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1203||||1203|757.89|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1203||||1203|177.09|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|1203||||1203|650|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1203||||1203|830.07|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1203||||1203|471.4|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1203||||1203|315.55|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1203||||1203|177.09|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1203||||1203|315.55|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1203||||1203|177.09|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1203||||1203|177.09|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1203||||1203|830.07|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1203||||1203|177.09|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|Self-pay|Self-pay|1203||||1203|421.05|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1203||||1203|177.09|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1203||||1203|177.09|830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1203||||1203||830.07|177.09
34178300|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1203||||1203||830.07|177.09
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|AARP [1000]|AARP [100000]|2345||||2345|650|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2345||||2345|345.4|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|AETNA [1015]|AETNA [101529]|2345||||2345|411.43|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2345||||2345|245.59|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2345||||2345|341.98|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2345||||2345|341.98|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|BCBS [1155]|BCBS UTHCT [115568]|2345||||2345|1102.15|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2345||||2345|336.7|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2345||||2345|1172.5|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2345||||2345|1477.35|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2345||||2345|245.59|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2345||||2345|341.98|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|CIGNA [1260]|CIGNA GWH [126023]|2345||||2345|650|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2345||||2345|1618.05|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2345||||2345|471.4|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2345||||2345|366.26|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2345||||2345|411.43|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2345||||2345|245.59|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2345||||2345|341.98|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2345||||2345|411.43|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2345||||2345|245.59|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2345||||2345|245.59|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2345||||2345|1618.05|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2345||||2345|245.59|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|Self-pay|Self-pay|2345||||2345|820.75|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2345||||2345|245.59|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2345||||2345|245.59|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2345||||2345|650|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2345||||2345|341.98|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2345||||2345|341.98|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2345||||2345|650|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2345||||2345|341.98|1618.05|245.59
34178306|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE WHOLE BODY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2345||||2345|683.95|1618.05|245.59
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|AARP [1000]|AARP [100000]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|AETNA [1015]|AETNA [101529]|3258||||3258|471|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3258||||3258|333.08|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|BCBS [1155]|BCBS UTHCT [115568]|3258||||3258|1531.26|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3258||||3258|382.24|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3258||||3258|1629|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3258||||3258|2052.54|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3258||||3258|333.08|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|CIGNA [1260]|CIGNA GWH [126023]|3258||||3258|650|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3258||||3258|2248.02|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3258||||3258|471.4|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3258||||3258|471|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3258||||3258|333.08|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3258||||3258|471|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3258||||3258|333.08|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3258||||3258|333.08|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3258||||3258|2248.02|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3258||||3258|333.08|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|Self-pay|Self-pay|3258||||3258|1140.3|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3258||||3258|333.08|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3258||||3258|333.08|2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3258||||3258||2248.02|333.08
34178315|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BONE 3 PHASE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3258||||3258||2248.02|333.08
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|AARP [1000]|AARP [100000]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|AETNA [1015]|AETNA [101529]|3447||||3447|429.26|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3447||||3447|326.45|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|BCBS [1155]|BCBS UTHCT [115568]|3447||||3447|1620.09|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3447||||3447|353.34|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3447||||3447|1723.5|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3447||||3447|2171.61|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3447||||3447|326.45|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|CIGNA [1260]|CIGNA GWH [126023]|3447||||3447|650|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3447||||3447|2378.43|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3447||||3447|1632.43|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3447||||3447|429.26|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3447||||3447|326.45|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3447||||3447|429.26|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3447||||3447|326.45|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3447||||3447|326.45|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3447||||3447|2378.43|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3447||||3447|326.45|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|Self-pay|Self-pay|3447||||3447|1206.45|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3447||||3447|326.45|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3447||||3447|326.45|2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3447||||3447||2378.43|326.45
34178451|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC SPECT SINGLE STUDY INCL WM EF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3447||||3447||2378.43|326.45
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|AARP [1000]|AARP [100000]|5813||||5813|650|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5813||||5813|1196.1|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|AETNA [1015]|AETNA [101529]|5813||||5813|621.24|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5813||||5813|454.41|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5813||||5813|1184.25|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5813||||5813|1184.25|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|BCBS [1155]|BCBS UTHCT [115568]|5813||||5813|2732.11|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5813||||5813|510.08|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5813||||5813|2906.5|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5813||||5813|3662.19|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5813||||5813|454.41|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5813||||5813|1184.25|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|CIGNA [1260]|CIGNA GWH [126023]|5813||||5813|650|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5813||||5813|4010.97|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5813||||5813|1632.43|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5813||||5813|1268.33|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5813||||5813|621.24|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5813||||5813|454.41|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5813||||5813|1184.25|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5813||||5813|621.24|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5813||||5813|454.41|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5813||||5813|454.41|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5813||||5813|4010.97|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5813||||5813|454.41|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|Self-pay|Self-pay|5813||||5813|2034.55|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5813||||5813|454.41|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5813||||5813|454.41|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5813||||5813|650|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5813||||5813|1184.25|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5813||||5813|1184.25|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5813||||5813|650|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5813||||5813|1184.25|4010.97|454.41
34178452|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MYOCARD PERFIMAGTOMO(SPECT)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5813||||5813|2368.51|4010.97|454.41
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|AARP [1000]|AARP [100000]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|AETNA [1015]|AETNA [101529]|2293||||2293|285.5|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2293||||2293|220.19|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|BCBS [1155]|BCBS UTHCT [115568]|2293||||2293|1077.71|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2293||||2293|233.81|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2293||||2293|1146.5|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2293||||2293|1444.59|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2293||||2293|220.19|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|CIGNA [1260]|CIGNA GWH [126023]|2293||||2293|650|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2293||||2293|1582.17|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2293||||2293|471.4|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2293||||2293|285.5|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2293||||2293|220.19|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2293||||2293|285.5|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2293||||2293|220.19|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2293||||2293|220.19|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2293||||2293|1582.17|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2293||||2293|220.19|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|Self-pay|Self-pay|2293||||2293|802.55|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2293||||2293|220.19|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2293||||2293|220.19|1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2293||||2293||1582.17|220.19
34178472|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC MUGA CARDIAC BLOOD POOL SINGLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2293||||2293||1582.17|220.19
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|AARP [1000]|AARP [100000]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|AETNA [1015]|AETNA [101529]|1374||||1374|259.9|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1374||||1374|179.1|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|BCBS [1155]|BCBS UTHCT [115568]|1374||||1374|645.78|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1374||||1374|210.17|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1374||||1374|687|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1374||||1374|865.62|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1374||||1374|179.1|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|CIGNA [1260]|CIGNA GWH [126023]|1374||||1374|650|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1374||||1374|948.06|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1374||||1374|471.4|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1374||||1374|259.9|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1374||||1374|179.1|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1374||||1374|259.9|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1374||||1374|179.1|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1374||||1374|179.1|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1374||||1374|948.06|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1374||||1374|179.1|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|Self-pay|Self-pay|1374||||1374|480.9|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1374||||1374|179.1|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1374||||1374|179.1|948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1374||||1374||948.06|179.1
34178579|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT IMAGING AEROSOL/GAS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1374||||1374||948.06|179.1
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AARP [1000]|AARP [100000]|1911||||1911|650|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1911||||1911|345.4|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AETNA [1015]|AETNA [101529]|1911||||1911|318.89|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1911||||1911|229.55|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1911||||1911|341.98|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1911||||1911|341.98|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS [1155]|BCBS UTHCT [115568]|1911||||1911|898.17|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1911||||1911|260.96|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1911||||1911|955.5|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1911||||1911|1203.93|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1911||||1911|229.55|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1911||||1911|341.98|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|CIGNA [1260]|CIGNA GWH [126023]|1911||||1911|650|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1911||||1911|1318.59|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1911||||1911|471.4|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1911||||1911|366.26|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1911||||1911|318.89|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1911||||1911|229.55|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1911||||1911|341.98|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1911||||1911|318.89|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1911||||1911|229.55|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1911||||1911|229.55|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1911||||1911|1318.59|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1911||||1911|229.55|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|Self-pay|Self-pay|1911||||1911|668.85|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1911||||1911|229.55|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1911||||1911|229.55|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1911||||1911|650|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1911||||1911|341.98|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1911||||1911|341.98|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1911||||1911|650|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1911||||1911|341.98|1318.59|229.55
34178580|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF PART|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1911||||1911|683.95|1318.59|229.55
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|AARP [1000]|AARP [100000]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|AETNA [1015]|AETNA [101529]|2216||||2216|447.07|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2216||||2216|322.1|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|BCBS [1155]|BCBS UTHCT [115568]|2216||||2216|1041.52|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2216||||2216|363.41|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2216||||2216|1108|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2216||||2216|1396.08|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2216||||2216|322.1|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|CIGNA [1260]|CIGNA GWH [126023]|2216||||2216|650|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2216||||2216|1529.04|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2216||||2216|611.75|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2216||||2216|447.07|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2216||||2216|322.1|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2216||||2216|447.07|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2216||||2216|322.1|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2216||||2216|322.1|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2216||||2216|1529.04|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2216||||2216|322.1|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|Self-pay|Self-pay|2216||||2216|775.6|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2216||||2216|322.1|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2216||||2216|322.1|1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2216||||2216||1529.04|322.1
34178582|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM VENT&PERF AEROSOL OR GAS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2216||||2216||1529.04|322.1
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|AARP [1000]|AARP [100000]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|AETNA [1015]|AETNA [101529]|2147||||2147|418.68|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2147||||2147|294.04|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|2147||||2147|1009.09|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2147||||2147|340.21|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2147||||2147|1073.5|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2147||||2147|1352.61|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2147||||2147|294.04|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|2147||||2147|650|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2147||||2147|1481.43|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2147||||2147|611.75|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2147||||2147|418.68|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2147||||2147|294.04|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2147||||2147|418.68|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2147||||2147|294.04|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2147||||2147|294.04|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2147||||2147|1481.43|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2147||||2147|294.04|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|Self-pay|Self-pay|2147||||2147|751.45|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2147||||2147|294.04|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2147||||2147|294.04|1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2147||||2147||1481.43|294.04
34178598|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC PULM PERF&VENT DIFF W/ OR W/O IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2147||||2147||1481.43|294.04
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|AARP [1000]|AARP [100000]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|AETNA [1015]|AETNA [101529]|1536||||1536|237.07|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1536||||1536|164.39|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|BCBS [1155]|BCBS UTHCT [115568]|1536||||1536|721.92|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1536||||1536|193.53|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1536||||1536|768|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1536||||1536|967.68|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1536||||1536|164.39|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|CIGNA [1260]|CIGNA GWH [126023]|1536||||1536|650|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1536||||1536|1059.84|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1536||||1536|471.4|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1536||||1536|237.07|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1536||||1536|164.39|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1536||||1536|237.07|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1536||||1536|164.39|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1536||||1536|164.39|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1536||||1536|1059.84|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1536||||1536|164.39|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|Self-pay|Self-pay|1536||||1536|537.6|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1536||||1536|164.39|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1536||||1536|164.39|1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1536||||1536||1059.84|164.39
34178700|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY SCAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1536||||1536||1059.84|164.39
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|AARP [1000]|AARP [100000]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|AETNA [1015]|AETNA [101529]|2067||||2067|295.68|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2067||||2067|223.54|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|BCBS [1155]|BCBS UTHCT [115568]|2067||||2067|971.49|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2067||||2067|240.38|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2067||||2067|1033.5|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2067||||2067|1302.21|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2067||||2067|223.54|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|CIGNA [1260]|CIGNA GWH [126023]|2067||||2067|650|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2067||||2067|1426.23|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2067||||2067|611.75|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2067||||2067|295.68|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2067||||2067|223.54|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2067||||2067|295.68|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2067||||2067|223.54|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2067||||2067|223.54|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2067||||2067|1426.23|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2067||||2067|223.54|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|Self-pay|Self-pay|2067||||2067|723.45|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2067||||2067|223.54|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2067||||2067|223.54|1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2067||||2067||1426.23|223.54
34178707|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VSC FLW/FNC SGL W/O RX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2067||||2067||1426.23|223.54
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|AARP [1000]|AARP [100000]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|AETNA [1015]|AETNA [101529]|2421||||2421|187.7|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2421||||2421|170.08|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|BCBS [1155]|BCBS UTHCT [115568]|2421||||2421|1137.87|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2421||||2421|151.06|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2421||||2421|1210.5|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2421||||2421|1525.23|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2421||||2421|170.08|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|CIGNA [1260]|CIGNA GWH [126023]|2421||||2421|650|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2421||||2421|1670.49|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2421||||2421|611.75|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2421||||2421|187.7|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2421||||2421|170.08|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2421||||2421|187.7|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2421||||2421|170.08|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2421||||2421|170.08|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2421||||2421|1670.49|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2421||||2421|170.08|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|Self-pay|Self-pay|2421||||2421|847.35|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2421||||2421|170.08|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2421||||2421|170.08|1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2421||||2421||1670.49|151.06
34178708|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC KIDNEY VASC FLW/FUNC SGL W/RX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2421||||2421||1670.49|151.06
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|AARP [1000]|AARP [100000]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|AETNA [1015]|AETNA [101529]|75||||75|75|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75||||75|22.24|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|BCBS [1155]|BCBS UTHCT [115568]|75||||75|35.25|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75||||75|75|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75||||75|37.5|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75||||75|47.25|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75||||75|22.24|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|CIGNA [1260]|CIGNA GWH [126023]|75||||75|75|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|75||||75|51.75|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|75||||75|37.5|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75||||75|75|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75||||75|22.24|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75||||75|75|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75||||75|22.24|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|75||||75|22.24|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|75||||75|51.75|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75||||75|22.24|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|Self-pay|Self-pay|75||||75|26.25|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|75||||75|22.24|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75||||75|22.24|75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75||||75||75|22.24
34178730|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC BLADDER RESIDUAL STUDY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75||||75||75|22.24
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|AARP [1000]|AARP [100000]|1371||||1371|650|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1371||||1371|345.4|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|AETNA [1015]|AETNA [101529]|1371||||1371|360.62|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1371||||1371|187.45|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1371||||1371|341.98|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1371||||1371|341.98|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|1371||||1371|644.37|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1371||||1371|205.35|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1371||||1371|685.5|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1371||||1371|863.73|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1371||||1371|187.45|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1371||||1371|341.98|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|1371||||1371|650|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1371||||1371|945.99|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1371||||1371|471.4|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1371||||1371|366.26|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1371||||1371|360.62|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1371||||1371|187.45|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1371||||1371|341.98|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1371||||1371|360.62|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1371||||1371|187.45|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1371||||1371|187.45|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1371||||1371|945.99|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1371||||1371|187.45|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|Self-pay|Self-pay|1371||||1371|479.85|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1371||||1371|187.45|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1371||||1371|187.45|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1371||||1371|650|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1371||||1371|341.98|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1371||||1371|341.98|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1371||||1371|650|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1371||||1371|341.98|945.99|187.45
34178800|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE PLNR 1 AREA SINGLE DAY IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1371||||1371|683.95|945.99|187.45
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|AARP [1000]|AARP [100000]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|AETNA [1015]|AETNA [101529]|3438||||3438|535.01|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3438||||3438|327.79|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|3438||||3438|1615.86|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3438||||3438|375.24|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3438||||3438|1719|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3438||||3438|2165.94|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3438||||3438|327.79|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|3438||||3438|650|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3438||||3438|2372.22|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3438||||3438|1632.43|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3438||||3438|535.01|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3438||||3438|327.79|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3438||||3438|535.01|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3438||||3438|327.79|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3438||||3438|327.79|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3438||||3438|2372.22|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3438||||3438|327.79|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|Self-pay|Self-pay|3438||||3438|1203.3|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3438||||3438|327.79|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3438||||3438|327.79|2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3438||||3438||2372.22|327.79
34178803|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCALIZE SPECT 1 AREA 1 DAY IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3438||||3438||2372.22|327.79
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|AARP [1000]|AARP [100000]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|AETNA [1015]|AETNA [101529]|5444||||5444|970.58|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5444||||5444|547.31|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|5444||||5444|2558.68|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5444||||5444|664.2|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5444||||5444|2722|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5444||||5444|3429.72|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5444||||5444|547.31|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|5444||||5444|650|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5444||||5444|3756.36|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5444||||5444|1632.43|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5444||||5444|970.58|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5444||||5444|547.31|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5444||||5444|970.58|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5444||||5444|547.31|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5444||||5444|547.31|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5444||||5444|3756.36|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5444||||5444|547.31|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|Self-pay|Self-pay|5444||||5444|1905.4|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5444||||5444|547.31|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5444||||5444|547.31|3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5444||||5444||3756.36|547.31
34178804|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ PLNR WHOLE BODY 2+DAY IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5444||||5444||3756.36|547.31
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|AARP [1000]|AARP [100000]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|AETNA [1015]|AETNA [101529]|3438||||3438|668.59|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3438||||3438|470.13|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|3438||||3438|1615.86|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3438||||3438|1543.4|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3438||||3438|1719|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3438||||3438|2165.94|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3438||||3438|470.13|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|3438||||3438|650|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3438||||3438|2372.22|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3438||||3438|1632.43|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3438||||3438|668.59|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3438||||3438|470.13|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3438||||3438|668.59|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3438||||3438|470.13|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3438||||3438|470.13|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3438||||3438|2372.22|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3438||||3438|470.13|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|Self-pay|Self-pay|3438||||3438|1203.3|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3438||||3438|470.13|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3438||||3438|470.13|2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3438||||3438||2372.22|470.13
34178830|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3438||||3438||2372.22|470.13
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AARP [1000]|AARP [100000]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AETNA [1015]|AETNA [101529]|3438||||3438|992.28|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3438||||3438|679.96|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS [1155]|BCBS UTHCT [115568]|3438||||3438|1615.86|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3438||||3438|1543.4|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3438||||3438|1719|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3438||||3438|2165.94|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3438||||3438|679.96|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|CIGNA [1260]|CIGNA GWH [126023]|3438||||3438|650|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3438||||3438|2372.22|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3438||||3438|1632.43|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3438||||3438|992.28|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3438||||3438|679.96|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3438||||3438|992.28|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3438||||3438|679.96|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3438||||3438|679.96|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3438||||3438|2372.22|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3438||||3438|679.96|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|Self-pay|Self-pay|3438||||3438|1203.3|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3438||||3438|679.96|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3438||||3438|679.96|2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3438||||3438||2372.22|650
34178831|EAP|0341 - NUCLEAR MEDICINE-DIAGNOSTIC|HC RP LOCLZJ TUM SPECT 2 AREA 1D IMG1 AREA IMG>2+D|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3438||||3438||2372.22|650
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201001|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201002|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201003|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201004|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201007|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201008|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201009|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201010|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201011|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201012|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201013|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201014|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201015|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201016|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201017|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201018|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201019|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201020|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201021|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201022|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34201023|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|10.02||||10.02|4.66|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.02||||10.02|2.97|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|10.02||||10.02|4.71|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.02||||10.02|0|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.02||||10.02|5.01|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.02||||10.02|6.31|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.02||||10.02|2.97|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|10.02||||10.02|5.51|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.02||||10.02|6.91|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.02||||10.02|2.23|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.02||||10.02|4.66|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.02||||10.02|2.97|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.02||||10.02|4.66|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.02||||10.02|2.97|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.02||||10.02|2.97|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.02||||10.02|6.91|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.02||||10.02|2.97|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|10.02||||10.02|3.51|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.02||||10.02|2.97|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.02||||10.02|2.97|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.02||||10.02||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|71.99||||71.99|46.56|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.99||||71.99|21.35|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|71.99||||71.99|33.84|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.99||||71.99|0|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.99||||71.99|36|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.99||||71.99|45.35|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.99||||71.99|21.35|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|71.99||||71.99|39.59|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|71.99||||71.99|49.67|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71.99||||71.99|2.23|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.99||||71.99|46.56|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.99||||71.99|21.35|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.99||||71.99|46.56|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.99||||71.99|21.35|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|71.99||||71.99|21.35|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|71.99||||71.99|49.67|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.99||||71.99|21.35|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|Self-pay|Self-pay|71.99||||71.99|25.2|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71.99||||71.99|21.35|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.99||||71.99|21.35|49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.99||||71.99||49.67|2.23
3426|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GENTAMICIN 40 MG/ML INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.99||||71.99||49.67|2.23
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AARP [1000]|AARP [100000]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AETNA [1015]|AETNA [101529]|96.6||||96.6|42.6|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|96.6||||96.6|28.64|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS [1155]|BCBS UTHCT [115568]|96.6||||96.6|45.4|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|96.6||||96.6|48.3|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|96.6||||96.6|48.3|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|96.6||||96.6|60.86|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|96.6||||96.6|28.64|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA GWH [126023]|96.6||||96.6|53.13|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|96.6||||96.6|66.65|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|96.6||||96.6|48.3|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|96.6||||96.6|42.6|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|96.6||||96.6|28.64|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|96.6||||96.6|42.6|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|96.6||||96.6|28.64|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|96.6||||96.6|28.64|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|96.6||||96.6|66.65|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|96.6||||96.6|28.64|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|Self-pay|Self-pay|96.6||||96.6|33.81|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|96.6||||96.6|28.64|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|96.6||||96.6|28.64|66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|96.6||||96.6||66.65|28.64
3427|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % (3 MG/GRAM) EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|96.6||||96.6||66.65|28.64
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AARP [1000]|AARP [100000]|78.12||||78.12|46|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|78.12||||78.12||53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AETNA [1015]|AETNA [101529]|78.12||||78.12|26.4|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|78.12||||78.12|23.16|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|78.12||||78.12||53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|78.12||||78.12||53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|78.12||||78.12|36.72|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|78.12||||78.12|0|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|78.12||||78.12|39.06|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|78.12||||78.12|49.22|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|78.12||||78.12|23.16|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|78.12||||78.12||53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|78.12||||78.12|42.97|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|78.12||||78.12|53.9|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|78.12||||78.12|0.15|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|78.12||||78.12||53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|78.12||||78.12|26.4|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|78.12||||78.12|23.16|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|78.12||||78.12||53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|78.12||||78.12|26.4|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|78.12||||78.12|23.16|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|78.12||||78.12|23.16|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|78.12||||78.12|53.9|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|78.12||||78.12|23.16|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|Self-pay|Self-pay|78.12||||78.12|27.34|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|78.12||||78.12|23.16|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|78.12||||78.12|23.16|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|78.12||||78.12|46|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|78.12||||78.12||53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|78.12||||78.12||53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|78.12||||78.12|46|53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|78.12||||78.12||53.9|0.15
34270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML IN 0.9 % SODIUM CHLORIDE INFUSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|78.12||||78.12||53.9|0.15
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|AARP [1000]|AARP [100000]|5259||||5259|650|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5259||||5259|228.63|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|AETNA [1015]|AETNA [101529]|5259||||5259|78.65|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5259||||5259|130.31|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5259||||5259|226.36|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5259||||5259|226.36|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|BCBS [1155]|BCBS UTHCT [115568]|5259||||5259|2471.73|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5259||||5259|61.29|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5259||||5259|2629.5|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5259||||5259|3313.17|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5259||||5259|130.31|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5259||||5259|226.36|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|CIGNA [1260]|CIGNA GWH [126023]|5259||||5259|650|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5259||||5259|3628.71|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5259||||5259|312.03|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5259||||5259|242.44|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5259||||5259|78.65|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5259||||5259|130.31|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5259||||5259|226.36|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5259||||5259|78.65|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5259||||5259|130.31|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5259||||5259|130.31|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5259||||5259|3628.71|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5259||||5259|130.31|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|Self-pay|Self-pay|5259||||5259|1840.65|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5259||||5259|130.31|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5259||||5259|130.31|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5259||||5259|650|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5259||||5259|226.36|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5259||||5259|226.36|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5259||||5259|650|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5259||||5259|226.36|3628.71|61.29
34279005|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC ORAL RADIOPHARM RX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5259||||5259|452.73|3628.71|61.29
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|AARP [1000]|AARP [100000]|5505||||5505|650|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5505||||5505|228.63|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|AETNA [1015]|AETNA [101529]|5505||||5505|79.75|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5505||||5505|136.66|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5505||||5505|226.36|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5505||||5505|226.36|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|BCBS [1155]|BCBS UTHCT [115568]|5505||||5505|2587.35|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5505||||5505|60.43|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5505||||5505|2752.5|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5505||||5505|3468.15|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5505||||5505|136.66|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5505||||5505|226.36|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|CIGNA [1260]|CIGNA GWH [126023]|5505||||5505|650|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5505||||5505|3798.45|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5505||||5505|312.03|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5505||||5505|242.44|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5505||||5505|79.75|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5505||||5505|136.66|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5505||||5505|226.36|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5505||||5505|79.75|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5505||||5505|136.66|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5505||||5505|136.66|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5505||||5505|3798.45|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5505||||5505|136.66|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|Self-pay|Self-pay|5505||||5505|1926.75|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5505||||5505|136.66|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5505||||5505|136.66|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5505||||5505|650|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5505||||5505|226.36|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5505||||5505|226.36|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5505||||5505|650|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5505||||5505|226.36|3798.45|60.43
34279101|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RADIOPH RX BY IV ADMIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5505||||5505|452.73|3798.45|60.43
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|AARP [1000]|AARP [100000]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|AETNA [1015]|AETNA [101529]|985||||985|127.42|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|985||||985|292.05|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|BCBS [1155]|BCBS UTHCT [115568]|985||||985|462.95|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|985||||985|103.77|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|985||||985|492.5|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|985||||985|620.55|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|985||||985|292.05|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|CIGNA [1260]|CIGNA GWH [126023]|985||||985|650|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|985||||985|679.65|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|985||||985|312.03|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|985||||985|127.42|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|985||||985|292.05|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|985||||985|127.42|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|985||||985|292.05|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|985||||985|292.05|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|985||||985|679.65|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|985||||985|292.05|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|Self-pay|Self-pay|985||||985|344.75|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|985||||985|292.05|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|985||||985|292.05|679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|985||||985||679.65|103.77
34279403|EAP|0342 - NUCLEAR MEDICINE-THERAPEUTIC|HC RPHARM MONOCLONAL AB THERAPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|985||||985||679.65|103.77
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|110.71||||110.71|48.82|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|110.71||||110.71|32.83|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|110.71||||110.71|52.03|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|110.71||||110.71|55.36|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|110.71||||110.71|55.36|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|110.71||||110.71|69.75|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|110.71||||110.71|32.83|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|110.71||||110.71|60.89|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|110.71||||110.71|76.39|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|110.71||||110.71|55.36|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|110.71||||110.71|48.82|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|110.71||||110.71|32.83|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|110.71||||110.71|48.82|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|110.71||||110.71|32.83|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|110.71||||110.71|32.83|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|110.71||||110.71|76.39|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|110.71||||110.71|32.83|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|110.71||||110.71|38.75|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|110.71||||110.71|32.83|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|110.71||||110.71|32.83|76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|110.71||||110.71||76.39|32.83
3428|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTAMICIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|110.71||||110.71||76.39|32.83
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|AARP [1000]|AARP [100000]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|AETNA [1015]|AETNA [101529]|10.61||||10.61|4.68|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.61||||10.61|3.15|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|BCBS [1155]|BCBS UTHCT [115568]|10.61||||10.61|4.99|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.61||||10.61|5.31|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.61||||10.61|5.31|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.61||||10.61|6.68|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.61||||10.61|3.15|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|CIGNA [1260]|CIGNA GWH [126023]|10.61||||10.61|5.84|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.61||||10.61|7.32|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.61||||10.61|5.31|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.61||||10.61|4.68|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.61||||10.61|3.15|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.61||||10.61|4.68|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.61||||10.61|3.15|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.61||||10.61|3.15|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.61||||10.61|7.32|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.61||||10.61|3.15|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|Self-pay|Self-pay|10.61||||10.61|3.71|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.61||||10.61|3.15|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.61||||10.61|3.15|7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.61||||10.61||7.32|3.15
3430|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GENTIAN VIOLET 1 % TOPICAL SOLUTION|59 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.61||||10.61||7.32|3.15
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.17||||2.17|0.96|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.17||||2.17|0.64|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.17||||2.17|1.02|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.17||||2.17|1.09|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.17||||2.17|1.09|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.17||||2.17|1.37|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.17||||2.17|0.64|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.17||||2.17|1.19|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.17||||2.17|1.5|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.17||||2.17|1.09|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.17||||2.17|0.96|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.17||||2.17|0.64|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.17||||2.17|0.96|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.17||||2.17|0.64|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.17||||2.17|0.64|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.17||||2.17|1.5|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.17||||2.17|0.64|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.17||||2.17|0.76|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.17||||2.17|0.64|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.17||||2.17|0.64|1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.17||||2.17||1.5|0.64
34369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.17||||2.17|0.96|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.17||||2.17|0.64|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.17||||2.17|1.02|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.17||||2.17|1.09|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.17||||2.17|1.09|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.17||||2.17|1.37|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.17||||2.17|0.64|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.17||||2.17|1.19|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.17||||2.17|1.5|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.17||||2.17|1.09|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.17||||2.17|0.96|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.17||||2.17|0.64|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.17||||2.17|0.96|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.17||||2.17|0.64|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.17||||2.17|0.64|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.17||||2.17|1.5|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.17||||2.17|0.64|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|Self-pay|Self-pay|2.17||||2.17|0.76|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.17||||2.17|0.64|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.17||||2.17|0.64|1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.17||||2.17||1.5|0.64
34370|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.17||||2.17||1.5|0.64
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.79||||2.79|1.23|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.79||||2.79|0.83|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.79||||2.79|1.31|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.79||||2.79|1.4|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.79||||2.79|1.4|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.79||||2.79|1.76|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.79||||2.79|0.83|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.79||||2.79|1.53|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.79||||2.79|1.93|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.79||||2.79|1.4|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.79||||2.79|1.23|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.79||||2.79|0.83|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.79||||2.79|1.23|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.79||||2.79|0.83|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.79||||2.79|0.83|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.79||||2.79|1.93|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.79||||2.79|0.83|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|Self-pay|Self-pay|2.79||||2.79|0.98|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.79||||2.79|0.83|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.79||||2.79|0.83|1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.79||||2.79||1.93|0.83
34371|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.79||||2.79|1.23|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.79||||2.79|0.83|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.79||||2.79|1.31|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.79||||2.79|1.4|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.79||||2.79|1.4|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.79||||2.79|1.76|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.79||||2.79|0.83|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.79||||2.79|1.53|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.79||||2.79|1.93|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.79||||2.79|1.4|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.79||||2.79|1.23|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.79||||2.79|0.83|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.79||||2.79|1.23|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.79||||2.79|0.83|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.79||||2.79|0.83|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.79||||2.79|1.93|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.79||||2.79|0.83|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|Self-pay|Self-pay|2.79||||2.79|0.98|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.79||||2.79|0.83|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.79||||2.79|0.83|1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.79||||2.79||1.93|0.83
34372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.79||||2.79||1.93|0.83
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|AARP [1000]|AARP [100000]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|AETNA [1015]|AETNA [101529]|294||||294|129.65|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|294||||294|87.17|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|BCBS [1155]|BCBS UTHCT [115568]|294||||294|138.18|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|294||||294|0|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|294||||294|147|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|294||||294|185.22|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|294||||294|87.17|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|CIGNA [1260]|CIGNA GWH [126023]|294||||294|161.7|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|294||||294|202.86|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|294||||294|179.24|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|294||||294|129.65|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|294||||294|87.17|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|294||||294|129.65|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|294||||294|87.17|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|294||||294|87.17|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|294||||294|202.86|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|294||||294|87.17|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|Self-pay|Self-pay|294||||294|102.9|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|294||||294|87.17|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|294||||294|87.17|202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|294||||294||202.86|87.17
34409606|EAP|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|HC RADIUM RA-223 DICHLORIDE, THERAP, PER MICROCURI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|294||||294||202.86|87.17
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|4.57||||4.57|2.02|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.57||||4.57|1.36|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.57||||4.57|2.15|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.57||||4.57|2.29|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.57||||4.57|2.29|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.57||||4.57|2.88|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.57||||4.57|1.36|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.57||||4.57|2.51|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.57||||4.57|3.15|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.57||||4.57|2.29|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.57||||4.57|2.02|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.57||||4.57|1.36|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.57||||4.57|2.02|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.57||||4.57|1.36|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.57||||4.57|1.36|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.57||||4.57|3.15|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.57||||4.57|1.36|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|4.57||||4.57|1.6|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.57||||4.57|1.36|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.57||||4.57|1.36|3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.57||||4.57||3.15|1.36
34418|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 250 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.57||||4.57||3.15|1.36
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|8.79||||8.79|3.88|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.79||||8.79|2.61|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|8.79||||8.79|4.13|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.79||||8.79|4.4|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.79||||8.79|4.4|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.79||||8.79|5.54|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.79||||8.79|2.61|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|8.79||||8.79|4.83|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|8.79||||8.79|6.07|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.79||||8.79|4.4|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.79||||8.79|3.88|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.79||||8.79|2.61|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.79||||8.79|3.88|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.79||||8.79|2.61|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.79||||8.79|2.61|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|8.79||||8.79|6.07|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.79||||8.79|2.61|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|Self-pay|Self-pay|8.79||||8.79|3.08|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.79||||8.79|2.61|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.79||||8.79|2.61|6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.79||||8.79||6.07|2.61
34444|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 10 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.79||||8.79||6.07|2.61
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|14.78||||14.78|6.52|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.78||||14.78|4.38|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|14.78||||14.78|6.95|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.78||||14.78|7.39|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.78||||14.78|7.39|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.78||||14.78|9.31|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.78||||14.78|4.38|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|14.78||||14.78|8.13|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|14.78||||14.78|10.2|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.78||||14.78|7.39|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.78||||14.78|6.52|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.78||||14.78|4.38|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.78||||14.78|6.52|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.78||||14.78|4.38|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.78||||14.78|4.38|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|14.78||||14.78|10.2|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.78||||14.78|4.38|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|Self-pay|Self-pay|14.78||||14.78|5.17|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.78||||14.78|4.38|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.78||||14.78|4.38|10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.78||||14.78||10.2|4.38
34447|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATOMOXETINE 40 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.78||||14.78||10.2|4.38
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.65||||1.65|0.73|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.65||||1.65|0.49|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.65||||1.65|0.78|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.65||||1.65|0.83|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.65||||1.65|0.83|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.65||||1.65|1.04|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.65||||1.65|0.49|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.65||||1.65|0.91|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.65||||1.65|1.14|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.65||||1.65|0.83|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.65||||1.65|0.73|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.65||||1.65|0.49|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.65||||1.65|0.73|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.65||||1.65|0.49|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.65||||1.65|0.49|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.65||||1.65|1.14|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.65||||1.65|0.49|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|Self-pay|Self-pay|1.65||||1.65|0.58|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.65||||1.65|0.49|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.65||||1.65|0.49|1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.65||||1.65||1.14|0.49
34505|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.65||||1.65||1.14|0.49
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.13||||1.13|0.5|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.13||||1.13|0.34|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.13||||1.13|0.53|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.13||||1.13|0.57|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.13||||1.13|0.57|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.13||||1.13|0.71|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.13||||1.13|0.34|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.13||||1.13|0.62|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.13||||1.13|0.78|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.13||||1.13|0.57|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.13||||1.13|0.5|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.13||||1.13|0.34|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.13||||1.13|0.5|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.13||||1.13|0.34|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.13||||1.13|0.34|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.13||||1.13|0.78|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.13||||1.13|0.34|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|Self-pay|Self-pay|1.13||||1.13|0.4|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.13||||1.13|0.34|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.13||||1.13|0.34|0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.13||||1.13||0.78|0.34
34544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.13||||1.13||0.78|0.34
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|267.52||||267.52|117.98|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|267.52||||267.52|79.32|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|267.52||||267.52|125.73|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|267.52||||267.52|0|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|267.52||||267.52|133.76|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|267.52||||267.52|168.54|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|267.52||||267.52|79.32|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|267.52||||267.52|147.14|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|267.52||||267.52|184.59|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|267.52||||267.52|133.76|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|267.52||||267.52|117.98|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|267.52||||267.52|79.32|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|267.52||||267.52|117.98|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|267.52||||267.52|79.32|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|267.52||||267.52|79.32|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|267.52||||267.52|184.59|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|267.52||||267.52|79.32|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|267.52||||267.52|93.63|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|267.52||||267.52|79.32|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|267.52||||267.52|79.32|184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|267.52||||267.52||184.59|79.32
34550|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEP B-DP(A)T-POLIO VACC (PF) 10 MCG-25LF-25 MCG-10LF/0.5 ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|267.52||||267.52||184.59|79.32
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|AARP [1000]|AARP [100000]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.96||||0.96|0.42|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.96||||0.96|0.28|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.96||||0.96|0.45|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.96||||0.96|0.48|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.96||||0.96|0.48|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.96||||0.96|0.6|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.96||||0.96|0.28|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.96||||0.96|0.53|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.96||||0.96|0.66|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.96||||0.96|0.48|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.96||||0.96|0.42|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.96||||0.96|0.28|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.96||||0.96|0.42|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.96||||0.96|0.28|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.96||||0.96|0.28|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.96||||0.96|0.66|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.96||||0.96|0.28|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|Self-pay|Self-pay|0.96||||0.96|0.34|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.96||||0.96|0.28|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.96||||0.96|0.28|0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.96||||0.96||0.66|0.28
34711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.96||||0.96||0.66|0.28
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|AARP [1000]|AARP [100000]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.86||||1.86|0.82|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.86||||1.86|0.55|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.86||||1.86|0.87|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.86||||1.86|0.93|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.86||||1.86|0.93|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.86||||1.86|1.17|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.86||||1.86|0.55|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.86||||1.86|1.02|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.86||||1.86|1.28|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.86||||1.86|0.93|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.86||||1.86|0.82|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.86||||1.86|0.55|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.86||||1.86|0.82|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.86||||1.86|0.55|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.86||||1.86|0.55|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.86||||1.86|1.28|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.86||||1.86|0.55|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|Self-pay|Self-pay|1.86||||1.86|0.65|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.86||||1.86|0.55|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.86||||1.86|0.55|1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.86||||1.86||1.28|0.55
34712|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPRENORPHINE HCL 8 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.86||||1.86||1.28|0.55
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901001|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901002|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901003|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901004|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901007|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901008|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901009|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901010|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901011|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901012|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901013|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901014|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901015|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901016|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901017|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901018|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901019|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901020|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901021|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901022|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
34901023|EAP|0349 - NUCLEAR MEDICINE-OTHER|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001001|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001002|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001003|EAP|0350 - CT SCAN-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001004|EAP|0350 - CT SCAN-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001007|EAP|0350 - CT SCAN-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001008|EAP|0350 - CT SCAN-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001009|EAP|0350 - CT SCAN-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001010|EAP|0350 - CT SCAN-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001011|EAP|0350 - CT SCAN-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001012|EAP|0350 - CT SCAN-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001013|EAP|0350 - CT SCAN-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001014|EAP|0350 - CT SCAN-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001015|EAP|0350 - CT SCAN-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001016|EAP|0350 - CT SCAN-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001017|EAP|0350 - CT SCAN-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001018|EAP|0350 - CT SCAN-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001019|EAP|0350 - CT SCAN-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001020|EAP|0350 - CT SCAN-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001021|EAP|0350 - CT SCAN-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001022|EAP|0350 - CT SCAN-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35001023|EAP|0350 - CT SCAN-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AARP [1000]|AARP [100000]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AETNA [1015]|AETNA [101529]|787||||787|660|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|787||||787|233.35|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS [1155]|BCBS UTHCT [115568]|787||||787|675|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|787||||787|16.64|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|787||||787|787|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|787||||787|787|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|787||||787|233.35|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|CIGNA [1260]|CIGNA GWH [126023]|787||||787|600|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|787||||787|543.03|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|787||||787|393.5|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|787||||787|660|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|787||||787|233.35|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|787||||787|660|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|787||||787|233.35|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|787||||787|233.35|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|787||||787|543.03|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|787||||787|233.35|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|Self-pay|Self-pay|787||||787|275.45|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|787||||787|233.35|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|787||||787|233.35|787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|787||||787||787|16.64
35076376|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER NOT REQ POSTPROC ON INDEP WS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|787||||787||787|16.64
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|AARP [1000]|AARP [100000]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|AETNA [1015]|AETNA [101529]|900||||900|660|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|900||||900|266.85|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|BCBS [1155]|BCBS UTHCT [115568]|900||||900|675|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|900||||900|38.53|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|900||||900|900|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|900||||900|900|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|900||||900|266.85|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|CIGNA [1260]|CIGNA GWH [126023]|900||||900|600|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|900||||900|621|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|900||||900|450|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|900||||900|660|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|900||||900|266.85|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|900||||900|660|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|900||||900|266.85|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|900||||900|266.85|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|900||||900|621|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|900||||900|266.85|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|Self-pay|Self-pay|900||||900|315|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|900||||900|266.85|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|900||||900|266.85|900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|900||||900||900|38.53
35076377|EAP|0350 - CT SCAN-GENERAL|HC 3D RENDER W POST PROCESS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|900||||900||900|38.53
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|AARP [1000]|AARP [100000]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|AETNA [1015]|AETNA [101529]|900||||900|660|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|900||||900|62.12|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|900||||900|675|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|900||||900|75.79|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|900||||900|900|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|900||||900|900|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|900||||900|62.12|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|900||||900|600|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|900||||900|621|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|900||||900|101.13|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|900||||900|660|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|900||||900|62.12|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|900||||900|660|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|900||||900|62.12|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|900||||900|62.12|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|900||||900|621|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|900||||900|62.12|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|Self-pay|Self-pay|900||||900|315|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|900||||900|62.12|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|900||||900|62.12|900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|900||||900||900|62.12
35076380|EAP|0350 - CT SCAN-GENERAL|HC CT FOLLOWUP/LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|900||||900||900|62.12
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|AARP [1000]|AARP [100000]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|AETNA [1015]|AETNA [101529]|2189||||2189|660|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2189||||2189|649.04|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|BCBS [1155]|BCBS UTHCT [115568]|2189||||2189|675|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2189||||2189|202.72|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2189||||2189|900|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2189||||2189|900|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2189||||2189|649.04|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|CIGNA [1260]|CIGNA GWH [126023]|2189||||2189|600|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2189||||2189|1510.41|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2189||||2189|1094.5|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2189||||2189|660|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2189||||2189|649.04|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2189||||2189|660|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2189||||2189|649.04|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2189||||2189|649.04|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2189||||2189|1510.41|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2189||||2189|649.04|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|Self-pay|Self-pay|2189||||2189|766.15|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2189||||2189|649.04|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2189||||2189|649.04|1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2189||||2189||1510.41|202.72
35077011|EAP|0350 - CT SCAN-GENERAL|HC GUIDED LOCALIZATION STEREO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2189||||2189||1510.41|202.72
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|AARP [1000]|AARP [100000]|2507||||2507|550|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2507||||2507||1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|AETNA [1015]|AETNA [101529]|2507||||2507|660|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2507||||2507|743.33|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2507||||2507||1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2507||||2507||1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|BCBS [1155]|BCBS UTHCT [115568]|2507||||2507|675|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2507||||2507|83.19|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2507||||2507|900|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2507||||2507|900|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2507||||2507|743.33|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2507||||2507||1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|CIGNA [1260]|CIGNA GWH [126023]|2507||||2507|600|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2507||||2507|1729.83|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2507||||2507|1253.5|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2507||||2507||1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2507||||2507|660|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2507||||2507|743.33|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2507||||2507||1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2507||||2507|660|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2507||||2507|743.33|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2507||||2507|743.33|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2507||||2507|1729.83|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2507||||2507|743.33|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|Self-pay|Self-pay|2507||||2507|877.45|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2507||||2507|743.33|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2507||||2507|743.33|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2507||||2507|550|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2507||||2507||1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2507||||2507||1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2507||||2507|550|1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2507||||2507||1729.83|83.19
35077012|EAP|0350 - CT SCAN-GENERAL|HC GUIDED NEEDLE BIOPSY/ASPIRATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2507||||2507||1729.83|83.19
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|AARP [1000]|AARP [100000]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|AETNA [1015]|AETNA [101529]|5054||||5054|660|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5054||||5054|1498.51|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|BCBS [1155]|BCBS UTHCT [115568]|5054||||5054|675|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5054||||5054|239.94|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5054||||5054|900|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5054||||5054|900|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5054||||5054|1498.51|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|CIGNA [1260]|CIGNA GWH [126023]|5054||||5054|600|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5054||||5054|3487.26|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5054||||5054|2527|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5054||||5054|660|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5054||||5054|1498.51|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5054||||5054|660|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5054||||5054|1498.51|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5054||||5054|1498.51|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5054||||5054|3487.26|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5054||||5054|1498.51|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|Self-pay|Self-pay|5054||||5054|1768.9|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5054||||5054|1498.51|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5054||||5054|1498.51|3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5054||||5054||3487.26|239.94
35077013|EAP|0350 - CT SCAN-GENERAL|HC GUIDANCE &MONITORING VISC TISS ABLATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5054||||5054||3487.26|239.94
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101001|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101002|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101003|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101004|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101007|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101008|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101009|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101010|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101011|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101012|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101013|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101014|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101015|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101016|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101017|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101018|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101019|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101020|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101021|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101022|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35101023|EAP|0351 - CT SCAN-HEAD SCAN|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.34||||4.34|1.91|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.34||||4.34|1.29|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.34||||4.34|2.04|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.34||||4.34|2.17|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.34||||4.34|2.17|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.34||||4.34|2.73|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.34||||4.34|1.29|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.34||||4.34|2.39|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.34||||4.34|2.99|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.34||||4.34|2.17|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.34||||4.34|1.91|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.34||||4.34|1.29|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.34||||4.34|1.91|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.34||||4.34|1.29|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.34||||4.34|1.29|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.34||||4.34|2.99|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.34||||4.34|1.29|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|4.34||||4.34|1.52|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.34||||4.34|1.29|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.34||||4.34|1.29|2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.34||||4.34||2.99|1.29
35134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.34||||4.34||2.99|1.29
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.87||||0.87|0.38|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.87||||0.87|0.26|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.87||||0.87|0.41|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.87||||0.87|0.44|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.87||||0.87|0.44|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.87||||0.87|0.55|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.87||||0.87|0.26|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.87||||0.87|0.48|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.87||||0.87|0.6|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.87||||0.87|0.44|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.87||||0.87|0.38|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.87||||0.87|0.26|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.87||||0.87|0.38|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.87||||0.87|0.26|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.87||||0.87|0.26|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.87||||0.87|0.6|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.87||||0.87|0.26|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.87||||0.87|0.3|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.87||||0.87|0.26|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.87||||0.87|0.26|0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.87||||0.87||0.6|0.26
35135|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.87||||0.87||0.6|0.26
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AARP [1000]|AARP [100000]|2061||||2061|550|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2061||||2061|99.8|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2061||||2061|660|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2061||||2061|109.6|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2061||||2061|98.82|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2061||||2061|98.82|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2061||||2061|675|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2061||||2061|139.64|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2061||||2061|900|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2061||||2061|900|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2061||||2061|109.6|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2061||||2061|98.82|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2061||||2061|600|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2061||||2061|1422.09|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2061||||2061|136.21|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2061||||2061|105.83|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2061||||2061|660|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2061||||2061|109.6|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2061||||2061|98.82|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2061||||2061|660|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2061||||2061|109.6|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2061||||2061|109.6|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2061||||2061|1422.09|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2061||||2061|109.6|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|Self-pay|Self-pay|2061||||2061|721.35|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2061||||2061|109.6|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2061||||2061|109.6|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2061||||2061|550|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2061||||2061|98.82|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2061||||2061|98.82|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2061||||2061|550|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2061||||2061|98.82|1422.09|98.82
35170450|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2061||||2061|197.63|1422.09|98.82
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|AARP [1000]|AARP [100000]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|AETNA [1015]|AETNA [101529]|2344||||2344|660|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2344||||2344|154.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2344||||2344|675|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2344||||2344|308.34|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2344||||2344|900|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2344||||2344|900|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2344||||2344|154.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2344||||2344|600|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2344||||2344|1617.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2344||||2344|223.19|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2344||||2344|660|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2344||||2344|154.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2344||||2344|660|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2344||||2344|154.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2344||||2344|154.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2344||||2344|1617.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2344||||2344|154.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|Self-pay|Self-pay|2344||||2344|820.4|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2344||||2344|154.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2344||||2344|154.36|1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2344||||2344||1617.36|154.36
35170460|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2344||||2344||1617.36|154.36
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2703||||2703|550|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2703||||2703|163.53|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2703||||2703|660|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2703||||2703|181.1|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2703||||2703|161.91|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2703||||2703|161.91|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2703||||2703|675|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2703||||2703|308.34|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2703||||2703|900|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2703||||2703|900|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2703||||2703|181.1|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2703||||2703|161.91|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2703||||2703|600|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2703||||2703|1865.07|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2703||||2703|223.19|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2703||||2703|173.41|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2703||||2703|660|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2703||||2703|181.1|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2703||||2703|161.91|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2703||||2703|660|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2703||||2703|181.1|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2703||||2703|181.1|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2703||||2703|1865.07|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2703||||2703|181.1|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|Self-pay|Self-pay|2703||||2703|946.05|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2703||||2703|181.1|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2703||||2703|181.1|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2703||||2703|550|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2703||||2703|161.91|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2703||||2703|161.91|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2703||||2703|550|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2703||||2703|161.91|1865.07|161.91
35170470|EAP|0351 - CT SCAN-HEAD SCAN|HC HEAD/BRAIN W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2703||||2703|323.83|1865.07|161.91
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|AARP [1000]|AARP [100000]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|1694||||1694|660|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1694||||1694|114.46|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1694||||1694|675|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1694||||1694|139.64|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1694||||1694|900|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1694||||1694|900|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1694||||1694|114.46|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1694||||1694|600|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1694||||1694|1168.86|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1694||||1694|136.21|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1694||||1694|660|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1694||||1694|114.46|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1694||||1694|660|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1694||||1694|114.46|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1694||||1694|114.46|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1694||||1694|1168.86|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1694||||1694|114.46|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|Self-pay|Self-pay|1694||||1694|592.9|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1694||||1694|114.46|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1694||||1694|114.46|1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1694||||1694||1168.86|114.46
35170480|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1694||||1694||1168.86|114.46
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|AARP [1000]|AARP [100000]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|AETNA [1015]|AETNA [101529]|1750||||1750|660|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1750||||1750|252.74|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1750||||1750|675|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1750||||1750|308.34|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1750||||1750|900|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1750||||1750|900|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1750||||1750|252.74|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1750||||1750|600|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1750||||1750|1207.5|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1750||||1750|223.19|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1750||||1750|660|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1750||||1750|252.74|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1750||||1750|660|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1750||||1750|252.74|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1750||||1750|252.74|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1750||||1750|1207.5|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1750||||1750|252.74|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|Self-pay|Self-pay|1750||||1750|612.5|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1750||||1750|252.74|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1750||||1750|252.74|1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1750||||1750||1207.5|223.19
35170481|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1750||||1750||1207.5|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|AARP [1000]|AARP [100000]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|AETNA [1015]|AETNA [101529]|2666||||2666|660|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2666||||2666|252.74|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|BCBS [1155]|BCBS UTHCT [115568]|2666||||2666|675|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2666||||2666|308.34|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2666||||2666|900|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2666||||2666|900|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2666||||2666|252.74|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|CIGNA [1260]|CIGNA GWH [126023]|2666||||2666|600|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2666||||2666|1839.54|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2666||||2666|223.19|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2666||||2666|660|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2666||||2666|252.74|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2666||||2666|660|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2666||||2666|252.74|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2666||||2666|252.74|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2666||||2666|1839.54|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2666||||2666|252.74|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|Self-pay|Self-pay|2666||||2666|933.1|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2666||||2666|252.74|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2666||||2666|252.74|1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2666||||2666||1839.54|223.19
35170482|EAP|0351 - CT SCAN-HEAD SCAN|HC ORBIT/SELLA/FOSSA/EAR W&WO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2666||||2666||1839.54|223.19
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|AARP [1000]|AARP [100000]|1815||||1815|550|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1815||||1815|99.8|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|1815||||1815|660|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1815||||1815|114.46|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1815||||1815|98.82|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1815||||1815|98.82|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1815||||1815|675|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1815||||1815|139.64|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1815||||1815|900|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1815||||1815|900|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1815||||1815|114.46|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1815||||1815|98.82|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1815||||1815|600|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1815||||1815|1252.35|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1815||||1815|136.21|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1815||||1815|105.83|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1815||||1815|660|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1815||||1815|114.46|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1815||||1815|98.82|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1815||||1815|660|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1815||||1815|114.46|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1815||||1815|114.46|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1815||||1815|1252.35|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1815||||1815|114.46|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|Self-pay|Self-pay|1815||||1815|635.25|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1815||||1815|114.46|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1815||||1815|114.46|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1815||||1815|550|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1815||||1815|98.82|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1815||||1815|98.82|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1815||||1815|550|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1815||||1815|98.82|1252.35|98.82
35170486|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1815||||1815|197.63|1252.35|98.82
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|AARP [1000]|AARP [100000]|2368||||2368|550|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2368||||2368|163.53|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|AETNA [1015]|AETNA [101529]|2368||||2368|660|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2368||||2368|158.38|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2368||||2368|161.91|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2368||||2368|161.91|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2368||||2368|675|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2368||||2368|308.34|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2368||||2368|900|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2368||||2368|900|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2368||||2368|158.38|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2368||||2368|161.91|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2368||||2368|600|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2368||||2368|1633.92|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2368||||2368|223.19|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2368||||2368|173.41|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2368||||2368|660|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2368||||2368|158.38|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2368||||2368|161.91|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2368||||2368|660|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2368||||2368|158.38|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2368||||2368|158.38|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2368||||2368|1633.92|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2368||||2368|158.38|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|Self-pay|Self-pay|2368||||2368|828.8|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2368||||2368|158.38|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2368||||2368|158.38|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2368||||2368|550|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2368||||2368|161.91|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2368||||2368|161.91|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2368||||2368|550|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2368||||2368|161.91|1633.92|158.38
35170487|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2368||||2368|323.83|1633.92|158.38
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2500||||2500|660|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2500||||2500|193.13|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2500||||2500|675|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2500||||2500|308.34|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2500||||2500|900|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2500||||2500|900|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2500||||2500|193.13|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2500||||2500|600|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2500||||2500|1725|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2500||||2500|223.19|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2500||||2500|660|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2500||||2500|193.13|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2500||||2500|660|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2500||||2500|193.13|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2500||||2500|193.13|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2500||||2500|1725|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2500||||2500|193.13|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|Self-pay|Self-pay|2500||||2500|875|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2500||||2500|193.13|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2500||||2500|193.13|1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2500||||2500||1725|193.13
35170488|EAP|0351 - CT SCAN-HEAD SCAN|HC FACIAL/SINUS W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2500||||2500||1725|193.13
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|AARP [1000]|AARP [100000]|2073||||2073|550|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2073||||2073|99.8|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2073||||2073|660|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2073||||2073|114.46|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2073||||2073|98.82|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2073||||2073|98.82|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2073||||2073|675|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2073||||2073|139.64|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2073||||2073|900|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2073||||2073|900|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2073||||2073|114.46|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2073||||2073|98.82|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2073||||2073|600|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2073||||2073|1430.37|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2073||||2073|136.21|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2073||||2073|105.83|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2073||||2073|660|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2073||||2073|114.46|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2073||||2073|98.82|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2073||||2073|660|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2073||||2073|114.46|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2073||||2073|114.46|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2073||||2073|1430.37|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2073||||2073|114.46|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|Self-pay|Self-pay|2073||||2073|725.55|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2073||||2073|114.46|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2073||||2073|114.46|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2073||||2073|550|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2073||||2073|98.82|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2073||||2073|98.82|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2073||||2073|550|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2073||||2073|98.82|1430.37|98.82
35170490|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2073||||2073|197.63|1430.37|98.82
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|AARP [1000]|AARP [100000]|2377||||2377|550|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2377||||2377|163.53|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|AETNA [1015]|AETNA [101529]|2377||||2377|660|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2377||||2377|192.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2377||||2377|161.91|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2377||||2377|161.91|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2377||||2377|675|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2377||||2377|308.34|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2377||||2377|900|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2377||||2377|900|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2377||||2377|192.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2377||||2377|161.91|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2377||||2377|600|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2377||||2377|1640.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2377||||2377|223.19|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2377||||2377|173.41|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2377||||2377|660|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2377||||2377|192.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2377||||2377|161.91|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2377||||2377|660|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2377||||2377|192.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2377||||2377|192.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2377||||2377|1640.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2377||||2377|192.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|Self-pay|Self-pay|2377||||2377|831.95|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2377||||2377|192.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2377||||2377|192.13|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2377||||2377|550|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2377||||2377|161.91|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2377||||2377|161.91|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2377||||2377|550|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2377||||2377|161.91|1640.13|161.91
35170491|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2377||||2377|323.83|1640.13|161.91
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2739||||2739|660|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2739||||2739|231.55|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2739||||2739|675|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2739||||2739|308.34|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2739||||2739|900|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2739||||2739|900|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2739||||2739|231.55|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2739||||2739|600|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2739||||2739|1889.91|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2739||||2739|223.19|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2739||||2739|660|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2739||||2739|231.55|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2739||||2739|660|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2739||||2739|231.55|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2739||||2739|231.55|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2739||||2739|1889.91|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2739||||2739|231.55|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|Self-pay|Self-pay|2739||||2739|958.65|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2739||||2739|231.55|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2739||||2739|231.55|1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2739||||2739||1889.91|223.19
35170492|EAP|0351 - CT SCAN-HEAD SCAN|HC NECK SOFT TISSUE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2739||||2739||1889.91|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2121||||2121|660|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2121||||2121|252.74|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2121||||2121|675|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2121||||2121|308.34|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2121||||2121|900|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2121||||2121|900|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2121||||2121|252.74|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2121||||2121|600|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2121||||2121|1463.49|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2121||||2121|223.19|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2121||||2121|660|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2121||||2121|252.74|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2121||||2121|660|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2121||||2121|252.74|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2121||||2121|252.74|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2121||||2121|1463.49|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2121||||2121|252.74|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|Self-pay|Self-pay|2121||||2121|742.35|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2121||||2121|252.74|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2121||||2121|252.74|1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2121||||2121||1463.49|223.19
35170496|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA HEAD W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2121||||2121||1463.49|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2246||||2246|660|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2246||||2246|252.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2246||||2246|675|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2246||||2246|308.34|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2246||||2246|900|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2246||||2246|900|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2246||||2246|252.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2246||||2246|600|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2246||||2246|1549.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2246||||2246|223.19|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2246||||2246|660|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2246||||2246|252.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2246||||2246|660|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2246||||2246|252.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2246||||2246|252.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2246||||2246|1549.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2246||||2246|252.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|Self-pay|Self-pay|2246||||2246|786.1|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2246||||2246|252.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2246||||2246|252.74|1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2246||||2246||1549.74|223.19
35170498|EAP|0351 - CT SCAN-HEAD SCAN|HC CTA NECK W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2246||||2246||1549.74|223.19
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.2||||0.2|0.09|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.2||||0.2|0.06|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.2||||0.2|0.09|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.2||||0.2|0.1|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.2||||0.2|0.1|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.2||||0.2|0.13|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.2||||0.2|0.06|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.2||||0.2|0.11|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.2||||0.2|0.14|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.2||||0.2|0.1|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.2||||0.2|0.09|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.2||||0.2|0.06|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.2||||0.2|0.09|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.2||||0.2|0.06|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.2||||0.2|0.06|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.2||||0.2|0.14|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.2||||0.2|0.06|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.2||||0.2|0.07|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.2||||0.2|0.06|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.2||||0.2|0.06|0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.2||||0.2||0.14|0.06
35184|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOBENZAPRINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.2||||0.2||0.14|0.06
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201001|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201002|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201003|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201004|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201007|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201008|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201009|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201010|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201011|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201012|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201013|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201014|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201015|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201016|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201017|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201018|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201019|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201020|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201021|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201022|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35201023|EAP|0352 - CT SCAN-BODY SCAN|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AARP [1000]|AARP [100000]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AETNA [1015]|AETNA [101529]|31.77||||31.77|14.01|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.77||||31.77|9.42|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS [1155]|BCBS UTHCT [115568]|31.77||||31.77|14.93|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.77||||31.77|15.89|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.77||||31.77|15.89|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.77||||31.77|20.02|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.77||||31.77|9.42|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|CIGNA [1260]|CIGNA GWH [126023]|31.77||||31.77|17.47|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|31.77||||31.77|21.92|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.77||||31.77|15.89|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.77||||31.77|14.01|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.77||||31.77|9.42|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.77||||31.77|14.01|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.77||||31.77|9.42|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.77||||31.77|9.42|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|31.77||||31.77|21.92|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.77||||31.77|9.42|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|Self-pay|Self-pay|31.77||||31.77|11.12|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.77||||31.77|9.42|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.77||||31.77|9.42|21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.77||||31.77||21.92|9.42
35209|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CYCLOSPORINE 0.05 % EYE DROPS IN A DROPPERETTE|0.4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.77||||31.77||21.92|9.42
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AARP [1000]|AARP [100000]|2322||||2322|550|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2322||||2322|99.8|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AETNA [1015]|AETNA [101529]|2322||||2322|660|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2322||||2322|114.46|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2322||||2322|98.82|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2322||||2322|98.82|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS [1155]|BCBS UTHCT [115568]|2322||||2322|675|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2322||||2322|139.64|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2322||||2322|900|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2322||||2322|900|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2322||||2322|114.46|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2322||||2322|98.82|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|CIGNA [1260]|CIGNA GWH [126023]|2322||||2322|600|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2322||||2322|1602.18|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2322||||2322|136.21|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2322||||2322|105.83|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2322||||2322|660|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2322||||2322|114.46|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2322||||2322|98.82|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2322||||2322|660|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2322||||2322|114.46|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2322||||2322|114.46|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2322||||2322|1602.18|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2322||||2322|114.46|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|Self-pay|Self-pay|2322||||2322|812.7|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2322||||2322|114.46|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2322||||2322|114.46|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2322||||2322|550|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2322||||2322|98.82|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2322||||2322|98.82|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2322||||2322|550|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2322||||2322|98.82|1602.18|98.82
35271250|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/O CON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2322||||2322|197.63|1602.18|98.82
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AARP [1000]|AARP [100000]|2712||||2712|550|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2712||||2712|163.53|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AETNA [1015]|AETNA [101529]|2712||||2712|660|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2712||||2712|185.78|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2712||||2712|161.91|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2712||||2712|161.91|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2712||||2712|1274.64|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2712||||2712|308.34|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2712||||2712|1356|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2712||||2712|1708.56|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2712||||2712|185.78|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2712||||2712|161.91|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2712||||2712|600|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2712||||2712|1871.28|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2712||||2712|223.19|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2712||||2712|173.41|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2712||||2712|660|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2712||||2712|185.78|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2712||||2712|161.91|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2712||||2712|660|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2712||||2712|185.78|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2712||||2712|185.78|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2712||||2712|1871.28|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2712||||2712|185.78|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|Self-pay|Self-pay|2712||||2712|949.2|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2712||||2712|185.78|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2712||||2712|185.78|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2712||||2712|550|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2712||||2712|161.91|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2712||||2712|161.91|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2712||||2712|550|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2712||||2712|161.91|1871.28|161.91
35271260|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W/ CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2712||||2712|323.83|1871.28|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|AARP [1000]|AARP [100000]|3311||||3311|550|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3311||||3311|163.53|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|AETNA [1015]|AETNA [101529]|3311||||3311|660|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3311||||3311|222.54|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3311||||3311|161.91|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3311||||3311|161.91|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3311||||3311|675|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3311||||3311|308.34|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3311||||3311|900|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3311||||3311|900|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3311||||3311|222.54|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3311||||3311|161.91|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3311||||3311|600|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3311||||3311|2284.59|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3311||||3311|223.19|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3311||||3311|173.41|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3311||||3311|660|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3311||||3311|222.54|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3311||||3311|161.91|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3311||||3311|660|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3311||||3311|222.54|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3311||||3311|222.54|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3311||||3311|2284.59|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3311||||3311|222.54|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|Self-pay|Self-pay|3311||||3311|1158.85|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3311||||3311|222.54|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3311||||3311|222.54|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3311||||3311|550|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3311||||3311|161.91|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3311||||3311|161.91|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3311||||3311|550|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3311||||3311|161.91|2284.59|161.91
35271270|EAP|0352 - CT SCAN-BODY SCAN|HC CHEST/THORAX DX W & WO CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3311||||3311|323.83|2284.59|161.91
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|AARP [1000]|AARP [100000]|220||||220|220|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|220||||220|74.1|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|AETNA [1015]|AETNA [101529]|220||||220|220|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|220||||220|80.9|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|220||||220|73.36|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|220||||220|73.36|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|220||||220|103.4|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|220||||220|126.18|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|220||||220|110|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|220||||220|138.6|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|220||||220|80.9|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|220||||220|73.36|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|220||||220|220|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|220||||220|151.8|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|220||||220|101.13|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|220||||220|78.57|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|220||||220|220|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|220||||220|80.9|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|220||||220|73.36|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|220||||220|220|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|220||||220|80.9|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|220||||220|80.9|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|220||||220|151.8|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|220||||220|80.9|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|Self-pay|Self-pay|220||||220|77|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|220||||220|80.9|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|220||||220|80.9|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|220||||220|220|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|220||||220|73.36|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|220||||220|73.36|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|220||||220|220|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|220||||220|73.36|220|73.36
35271271|EAP|0352 - CT SCAN-BODY SCAN|HC LDCT FOR LUNG CA SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|220||||220|146.73|220|73.36
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2932||||2932|550|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2932||||2932|163.53|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2932||||2932|660|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2932||||2932|252.74|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2932||||2932|161.91|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2932||||2932|161.91|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2932||||2932|675|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2932||||2932|308.34|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2932||||2932|900|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2932||||2932|900|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2932||||2932|252.74|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2932||||2932|161.91|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2932||||2932|600|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2932||||2932|2023.08|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2932||||2932|223.19|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2932||||2932|173.41|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2932||||2932|660|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2932||||2932|252.74|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2932||||2932|161.91|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2932||||2932|660|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2932||||2932|252.74|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2932||||2932|252.74|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2932||||2932|2023.08|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2932||||2932|252.74|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|Self-pay|Self-pay|2932||||2932|1026.2|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2932||||2932|252.74|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2932||||2932|252.74|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2932||||2932|550|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2932||||2932|161.91|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2932||||2932|161.91|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2932||||2932|550|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2932||||2932|161.91|2023.08|161.91
35271275|EAP|0352 - CT SCAN-BODY SCAN|HC CTA CHEST W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2932||||2932|323.83|2023.08|161.91
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|AARP [1000]|AARP [100000]|2381||||2381|550|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2381||||2381|99.8|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2381||||2381|660|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2381||||2381|114.46|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2381||||2381|98.82|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2381||||2381|98.82|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2381||||2381|675|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2381||||2381|139.64|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2381||||2381|900|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2381||||2381|900|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2381||||2381|114.46|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2381||||2381|98.82|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2381||||2381|600|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2381||||2381|1642.89|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2381||||2381|136.21|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2381||||2381|105.83|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2381||||2381|660|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2381||||2381|114.46|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2381||||2381|98.82|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2381||||2381|660|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2381||||2381|114.46|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2381||||2381|114.46|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2381||||2381|1642.89|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2381||||2381|114.46|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|Self-pay|Self-pay|2381||||2381|833.35|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2381||||2381|114.46|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2381||||2381|114.46|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2381||||2381|550|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2381||||2381|98.82|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2381||||2381|98.82|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2381||||2381|550|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2381||||2381|98.82|1642.89|98.82
35272125|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2381||||2381|197.63|1642.89|98.82
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|AARP [1000]|AARP [100000]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|AETNA [1015]|AETNA [101529]|2500||||2500|660|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2500||||2500|215.51|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2500||||2500|675|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2500||||2500|556.77|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2500||||2500|900|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2500||||2500|900|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2500||||2500|215.51|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2500||||2500|600|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2500||||2500|1725|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2500||||2500|460.15|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2500||||2500|660|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2500||||2500|215.51|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2500||||2500|660|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2500||||2500|215.51|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2500||||2500|215.51|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2500||||2500|1725|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2500||||2500|215.51|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|Self-pay|Self-pay|2500||||2500|875|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2500||||2500|215.51|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2500||||2500|215.51|1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2500||||2500||1725|215.51
35272126|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2500||||2500||1725|215.51
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2700||||2700|660|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2700||||2700|252.74|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2700||||2700|675|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2700||||2700|308.34|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2700||||2700|900|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2700||||2700|900|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2700||||2700|252.74|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2700||||2700|600|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2700||||2700|1863|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2700||||2700|223.19|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2700||||2700|660|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2700||||2700|252.74|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2700||||2700|660|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2700||||2700|252.74|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2700||||2700|252.74|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2700||||2700|1863|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2700||||2700|252.74|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|Self-pay|Self-pay|2700||||2700|945|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2700||||2700|252.74|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2700||||2700|252.74|1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2700||||2700||1863|223.19
35272127|EAP|0352 - CT SCAN-BODY SCAN|HC C-SPINE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2700||||2700||1863|223.19
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|AARP [1000]|AARP [100000]|2184||||2184|550|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2184||||2184|99.8|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2184||||2184|660|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2184||||2184|114.46|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2184||||2184|98.82|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2184||||2184|98.82|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2184||||2184|675|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2184||||2184|139.64|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2184||||2184|900|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2184||||2184|900|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2184||||2184|114.46|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2184||||2184|98.82|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2184||||2184|600|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2184||||2184|1506.96|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2184||||2184|136.21|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2184||||2184|105.83|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2184||||2184|660|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2184||||2184|114.46|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2184||||2184|98.82|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2184||||2184|660|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2184||||2184|114.46|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2184||||2184|114.46|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2184||||2184|1506.96|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2184||||2184|114.46|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|Self-pay|Self-pay|2184||||2184|764.4|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2184||||2184|114.46|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2184||||2184|114.46|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2184||||2184|550|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2184||||2184|98.82|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2184||||2184|98.82|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2184||||2184|550|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2184||||2184|98.82|1506.96|98.82
35272128|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2184||||2184|197.63|1506.96|98.82
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|AARP [1000]|AARP [100000]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|AETNA [1015]|AETNA [101529]|2300||||2300|660|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2300||||2300|216.51|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2300||||2300|675|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2300||||2300|308.34|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2300||||2300|900|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2300||||2300|900|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2300||||2300|216.51|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2300||||2300|600|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2300||||2300|1587|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2300||||2300|223.19|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2300||||2300|660|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2300||||2300|216.51|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2300||||2300|660|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2300||||2300|216.51|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2300||||2300|216.51|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2300||||2300|1587|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2300||||2300|216.51|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|Self-pay|Self-pay|2300||||2300|805|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2300||||2300|216.51|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2300||||2300|216.51|1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2300||||2300||1587|216.51
35272129|EAP|0352 - CT SCAN-BODY SCAN|HC T-SPINE W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2300||||2300||1587|216.51
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|AARP [1000]|AARP [100000]|2437||||2437|550|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2437||||2437|99.8|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2437||||2437|660|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2437||||2437|114.46|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2437||||2437|98.82|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2437||||2437|98.82|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2437||||2437|675|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2437||||2437|139.64|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2437||||2437|900|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2437||||2437|900|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2437||||2437|114.46|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2437||||2437|98.82|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2437||||2437|600|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2437||||2437|1681.53|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2437||||2437|136.21|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2437||||2437|105.83|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2437||||2437|660|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2437||||2437|114.46|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2437||||2437|98.82|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2437||||2437|660|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2437||||2437|114.46|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2437||||2437|114.46|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2437||||2437|1681.53|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2437||||2437|114.46|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|Self-pay|Self-pay|2437||||2437|852.95|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2437||||2437|114.46|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2437||||2437|114.46|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2437||||2437|550|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2437||||2437|98.82|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2437||||2437|98.82|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2437||||2437|550|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2437||||2437|98.82|1681.53|98.82
35272131|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2437||||2437|197.63|1681.53|98.82
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AARP [1000]|AARP [100000]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AETNA [1015]|AETNA [101529]|2600||||2600|660|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2600||||2600|215.51|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2600||||2600|675|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2600||||2600|556.77|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2600||||2600|900|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2600||||2600|900|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2600||||2600|215.51|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2600||||2600|600|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2600||||2600|1794|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2600||||2600|460.15|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2600||||2600|660|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2600||||2600|215.51|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2600||||2600|660|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2600||||2600|215.51|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2600||||2600|215.51|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2600||||2600|1794|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2600||||2600|215.51|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|Self-pay|Self-pay|2600||||2600|910|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2600||||2600|215.51|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2600||||2600|215.51|1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2600||||2600||1794|215.51
35272132|EAP|0352 - CT SCAN-BODY SCAN|HC L-SPINE W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2600||||2600||1794|215.51
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2886||||2886|660|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2886||||2886|252.74|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2886||||2886|675|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2886||||2886|308.34|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2886||||2886|900|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2886||||2886|900|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2886||||2886|252.74|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2886||||2886|600|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2886||||2886|1991.34|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2886||||2886|223.19|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2886||||2886|660|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2886||||2886|252.74|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2886||||2886|660|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2886||||2886|252.74|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2886||||2886|252.74|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2886||||2886|1991.34|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2886||||2886|252.74|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|Self-pay|Self-pay|2886||||2886|1010.1|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2886||||2886|252.74|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2886||||2886|252.74|1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2886||||2886||1991.34|223.19
35272133|EAP|0352 - CT SCAN-BODY SCAN|HC LUMBAR SPINE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2886||||2886||1991.34|223.19
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|AARP [1000]|AARP [100000]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2312||||2312|660|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2312||||2312|114.46|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2312||||2312|675|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2312||||2312|139.64|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2312||||2312|900|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2312||||2312|900|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2312||||2312|114.46|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2312||||2312|600|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2312||||2312|1595.28|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2312||||2312|136.21|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2312||||2312|660|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2312||||2312|114.46|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2312||||2312|660|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2312||||2312|114.46|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2312||||2312|114.46|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2312||||2312|1595.28|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2312||||2312|114.46|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|Self-pay|Self-pay|2312||||2312|809.2|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2312||||2312|114.46|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2312||||2312|114.46|1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2312||||2312||1595.28|114.46
35272192|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2312||||2312||1595.28|114.46
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|AARP [1000]|AARP [100000]|2594||||2594|550|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2594||||2594|163.53|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|AETNA [1015]|AETNA [101529]|2594||||2594|660|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2594||||2594|213.51|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2594||||2594|161.91|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2594||||2594|161.91|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2594||||2594|675|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2594||||2594|308.34|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2594||||2594|900|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2594||||2594|900|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2594||||2594|213.51|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2594||||2594|161.91|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2594||||2594|600|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2594||||2594|1789.86|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2594||||2594|223.19|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2594||||2594|173.41|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2594||||2594|660|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2594||||2594|213.51|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2594||||2594|161.91|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2594||||2594|660|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2594||||2594|213.51|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2594||||2594|213.51|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2594||||2594|1789.86|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2594||||2594|213.51|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|Self-pay|Self-pay|2594||||2594|907.9|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2594||||2594|213.51|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2594||||2594|213.51|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2594||||2594|550|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2594||||2594|161.91|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2594||||2594|161.91|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2594||||2594|550|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2594||||2594|161.91|1789.86|161.91
35272193|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2594||||2594|323.83|1789.86|161.91
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2898||||2898|660|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2898||||2898|245.93|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2898||||2898|675|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2898||||2898|308.34|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2898||||2898|900|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2898||||2898|900|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2898||||2898|245.93|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2898||||2898|600|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2898||||2898|1999.62|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2898||||2898|223.19|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2898||||2898|660|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2898||||2898|245.93|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2898||||2898|660|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2898||||2898|245.93|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2898||||2898|245.93|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2898||||2898|1999.62|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2898||||2898|245.93|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|Self-pay|Self-pay|2898||||2898|1014.3|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2898||||2898|245.93|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2898||||2898|245.93|1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2898||||2898||1999.62|223.19
35272194|EAP|0352 - CT SCAN-BODY SCAN|HC PELVIS W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2898||||2898||1999.62|223.19
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|AARP [1000]|AARP [100000]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|1932||||1932|660|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1932||||1932|114.46|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1932||||1932|675|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1932||||1932|139.64|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1932||||1932|900|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1932||||1932|900|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1932||||1932|114.46|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1932||||1932|600|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1932||||1932|1333.08|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1932||||1932|136.21|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1932||||1932|660|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1932||||1932|114.46|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1932||||1932|660|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1932||||1932|114.46|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1932||||1932|114.46|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1932||||1932|1333.08|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1932||||1932|114.46|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|Self-pay|Self-pay|1932||||1932|676.2|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1932||||1932|114.46|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1932||||1932|114.46|1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1932||||1932||1333.08|114.46
35273200|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1932||||1932||1333.08|114.46
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AARP [1000]|AARP [100000]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AETNA [1015]|AETNA [101529]|2169||||2169|660|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2169||||2169|210.5|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2169||||2169|675|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2169||||2169|308.34|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2169||||2169|900|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2169||||2169|900|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2169||||2169|210.5|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2169||||2169|600|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2169||||2169|1496.61|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2169||||2169|460.15|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2169||||2169|660|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2169||||2169|210.5|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2169||||2169|660|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2169||||2169|210.5|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2169||||2169|210.5|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2169||||2169|1496.61|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2169||||2169|210.5|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|Self-pay|Self-pay|2169||||2169|759.15|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2169||||2169|210.5|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2169||||2169|210.5|1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2169||||2169||1496.61|210.5
35273201|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2169||||2169||1496.61|210.5
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2400||||2400|660|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2400||||2400|252.74|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2400||||2400|675|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2400||||2400|308.34|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2400||||2400|900|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2400||||2400|900|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2400||||2400|252.74|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2400||||2400|600|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2400||||2400|1656|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2400||||2400|223.19|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2400||||2400|660|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2400||||2400|252.74|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2400||||2400|660|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2400||||2400|252.74|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2400||||2400|252.74|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2400||||2400|1656|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2400||||2400|252.74|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|Self-pay|Self-pay|2400||||2400|840|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2400||||2400|252.74|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2400||||2400|252.74|1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2400||||2400||1656|223.19
35273202|EAP|0352 - CT SCAN-BODY SCAN|HC UPPER EXT W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2400||||2400||1656|223.19
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|AARP [1000]|AARP [100000]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|1928||||1928|660|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1928||||1928|114.46|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1928||||1928|675|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1928||||1928|139.64|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1928||||1928|900|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1928||||1928|900|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1928||||1928|114.46|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1928||||1928|600|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1928||||1928|1330.32|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1928||||1928|136.21|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1928||||1928|660|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1928||||1928|114.46|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1928||||1928|660|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1928||||1928|114.46|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1928||||1928|114.46|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1928||||1928|1330.32|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1928||||1928|114.46|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|Self-pay|Self-pay|1928||||1928|674.8|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1928||||1928|114.46|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1928||||1928|114.46|1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1928||||1928||1330.32|114.46
35273700|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1928||||1928||1330.32|114.46
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|AARP [1000]|AARP [100000]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|AETNA [1015]|AETNA [101529]|2141||||2141|660|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2141||||2141|213.51|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2141||||2141|675|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2141||||2141|308.34|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2141||||2141|900|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2141||||2141|900|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2141||||2141|213.51|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2141||||2141|600|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2141||||2141|1477.29|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2141||||2141|223.19|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2141||||2141|660|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2141||||2141|213.51|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2141||||2141|660|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2141||||2141|213.51|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2141||||2141|213.51|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2141||||2141|1477.29|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2141||||2141|213.51|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|Self-pay|Self-pay|2141||||2141|749.35|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2141||||2141|213.51|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2141||||2141|213.51|1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2141||||2141||1477.29|213.51
35273701|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2141||||2141||1477.29|213.51
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|AARP [1000]|AARP [100000]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|AETNA [1015]|AETNA [101529]|2585||||2585|660|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2585||||2585|252.74|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|BCBS [1155]|BCBS UTHCT [115568]|2585||||2585|675|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2585||||2585|308.34|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2585||||2585|900|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2585||||2585|900|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2585||||2585|252.74|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|CIGNA [1260]|CIGNA GWH [126023]|2585||||2585|600|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2585||||2585|1783.65|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2585||||2585|223.19|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2585||||2585|660|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2585||||2585|252.74|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2585||||2585|660|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2585||||2585|252.74|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2585||||2585|252.74|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2585||||2585|1783.65|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2585||||2585|252.74|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|Self-pay|Self-pay|2585||||2585|904.75|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2585||||2585|252.74|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2585||||2585|252.74|1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2585||||2585||1783.65|223.19
35273702|EAP|0352 - CT SCAN-BODY SCAN|HC LOWER EXT W/ & W/O CONT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2585||||2585||1783.65|223.19
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AARP [1000]|AARP [100000]|2827||||2827|550|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2827||||2827|163.53|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AETNA [1015]|AETNA [101529]|2827||||2827|660|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2827||||2827|252.74|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2827||||2827|161.91|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2827||||2827|161.91|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BCBS UTHCT [115568]|2827||||2827|675|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2827||||2827|308.34|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2827||||2827|900|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2827||||2827|900|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2827||||2827|252.74|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2827||||2827|161.91|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA [1260]|CIGNA GWH [126023]|2827||||2827|600|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2827||||2827|1950.63|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2827||||2827|223.19|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2827||||2827|173.41|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2827||||2827|660|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2827||||2827|252.74|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2827||||2827|161.91|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2827||||2827|660|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2827||||2827|252.74|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2827||||2827|252.74|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2827||||2827|1950.63|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2827||||2827|252.74|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|Self-pay|Self-pay|2827||||2827|989.45|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2827||||2827|252.74|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2827||||2827|252.74|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2827||||2827|550|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2827||||2827|161.91|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2827||||2827|161.91|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2827||||2827|550|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2827||||2827|161.91|1950.63|161.91
35273706|EAP|0352 - CT SCAN-BODY SCAN|HC CTA LOWER EXT W/CONT+NONCONTRAST IMG IF DONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2827||||2827|323.83|1950.63|161.91
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|AARP [1000]|AARP [100000]|2203||||2203|550|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2203||||2203|99.8|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2203||||2203|660|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2203||||2203|114.46|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2203||||2203|98.82|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2203||||2203|98.82|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2203||||2203|675|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2203||||2203|139.64|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2203||||2203|900|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2203||||2203|900|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2203||||2203|114.46|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2203||||2203|98.82|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2203||||2203|600|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2203||||2203|1520.07|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2203||||2203|136.21|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2203||||2203|105.83|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2203||||2203|660|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2203||||2203|114.46|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2203||||2203|98.82|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2203||||2203|660|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2203||||2203|114.46|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2203||||2203|114.46|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2203||||2203|1520.07|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2203||||2203|114.46|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|Self-pay|Self-pay|2203||||2203|771.05|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2203||||2203|114.46|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2203||||2203|114.46|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2203||||2203|550|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2203||||2203|98.82|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2203||||2203|98.82|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2203||||2203|550|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2203||||2203|98.82|1520.07|98.82
35274150|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2203||||2203|197.63|1520.07|98.82
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|AARP [1000]|AARP [100000]|2735||||2735|550|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2735||||2735|163.53|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|AETNA [1015]|AETNA [101529]|2735||||2735|660|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2735||||2735|218.19|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2735||||2735|161.91|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2735||||2735|161.91|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2735||||2735|675|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2735||||2735|308.34|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2735||||2735|900|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2735||||2735|900|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2735||||2735|218.19|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2735||||2735|161.91|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2735||||2735|600|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2735||||2735|1887.15|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2735||||2735|223.19|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2735||||2735|173.41|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2735||||2735|660|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2735||||2735|218.19|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2735||||2735|161.91|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2735||||2735|660|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2735||||2735|218.19|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2735||||2735|218.19|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2735||||2735|1887.15|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2735||||2735|218.19|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|Self-pay|Self-pay|2735||||2735|957.25|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2735||||2735|218.19|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2735||||2735|218.19|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2735||||2735|550|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2735||||2735|161.91|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2735||||2735|161.91|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2735||||2735|550|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2735||||2735|161.91|1887.15|161.91
35274160|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2735||||2735|323.83|1887.15|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|3081||||3081|550|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3081||||3081|163.53|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3081||||3081|660|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3081||||3081|248.26|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3081||||3081|161.91|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3081||||3081|161.91|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3081||||3081|675|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3081||||3081|308.34|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3081||||3081|900|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3081||||3081|900|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3081||||3081|248.26|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3081||||3081|161.91|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3081||||3081|600|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3081||||3081|2125.89|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3081||||3081|223.19|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3081||||3081|173.41|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3081||||3081|660|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3081||||3081|248.26|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3081||||3081|161.91|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3081||||3081|660|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3081||||3081|248.26|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3081||||3081|248.26|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3081||||3081|2125.89|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3081||||3081|248.26|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|Self-pay|Self-pay|3081||||3081|1078.35|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3081||||3081|248.26|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3081||||3081|248.26|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3081||||3081|550|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3081||||3081|161.91|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3081||||3081|161.91|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3081||||3081|550|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3081||||3081|161.91|2125.89|161.91
35274170|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOMEN W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3081||||3081|323.83|2125.89|161.91
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AARP [1000]|AARP [100000]|2629||||2629|550|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2629||||2629|337.15|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AETNA [1015]|AETNA [101529]|2629||||2629|660|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2629||||2629|252.74|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2629||||2629|333.81|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2629||||2629|333.81|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BCBS UTHCT [115568]|2629||||2629|1235.63|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2629||||2629|307.37|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2629||||2629|1314.5|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2629||||2629|1656.27|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2629||||2629|252.74|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2629||||2629|333.81|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA [1260]|CIGNA GWH [126023]|2629||||2629|600|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2629||||2629|1814.01|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2629||||2629|460.15|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2629||||2629|357.52|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2629||||2629|660|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2629||||2629|252.74|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2629||||2629|333.81|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2629||||2629|660|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2629||||2629|252.74|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2629||||2629|252.74|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2629||||2629|1814.01|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2629||||2629|252.74|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|Self-pay|Self-pay|2629||||2629|920.15|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2629||||2629|252.74|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2629||||2629|252.74|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2629||||2629|550|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2629||||2629|333.81|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2629||||2629|333.81|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2629||||2629|550|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2629||||2629|333.81|1814.01|252.74
35274174|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD/PELV W/CONT+NONCONTRAST IMG IF DONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2629||||2629|667.63|1814.01|252.74
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|AARP [1000]|AARP [100000]|900||||900|550|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|900||||900|163.53|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|AETNA [1015]|AETNA [101529]|900||||900|660|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|900||||900|252.74|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|900||||900|161.91|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|900||||900|161.91|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BCBS UTHCT [115568]|900||||900|675|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|900||||900|308.34|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|900||||900|900|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|900||||900|900|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|900||||900|252.74|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|900||||900|161.91|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|CIGNA [1260]|CIGNA GWH [126023]|900||||900|600|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|900||||900|621|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|900||||900|223.19|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|900||||900|173.41|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|900||||900|660|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|900||||900|252.74|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|900||||900|161.91|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|900||||900|660|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|900||||900|252.74|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|900||||900|252.74|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|900||||900|621|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|900||||900|252.74|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|Self-pay|Self-pay|900||||900|315|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|900||||900|252.74|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|900||||900|252.74|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|900||||900|550|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|900||||900|161.91|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|900||||900|161.91|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|900||||900|550|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|900||||900|161.91|900|161.91
35274175|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABDOMEN W/CONT+NONCONTRAST IMG IF DONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|900||||900|323.83|900|161.91
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AARP [1000]|AARP [100000]|1908||||1908|550|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1908||||1908|210.77|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|1908||||1908|660|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1908||||1908|189.79|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1908||||1908|208.68|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1908||||1908|208.68|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1908||||1908|896.76|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1908||||1908|283.42|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1908||||1908|954|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1908||||1908|1202.04|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1908||||1908|189.79|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1908||||1908|208.68|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1908||||1908|600|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1908||||1908|1316.52|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1908||||1908|287.66|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1908||||1908|223.5|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1908||||1908|660|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1908||||1908|189.79|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1908||||1908|208.68|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1908||||1908|660|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1908||||1908|189.79|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1908||||1908|189.79|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1908||||1908|1316.52|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1908||||1908|189.79|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|Self-pay|Self-pay|1908||||1908|667.8|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1908||||1908|189.79|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1908||||1908|189.79|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1908||||1908|550|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1908||||1908|208.68|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1908||||1908|208.68|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1908||||1908|550|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1908||||1908|208.68|1316.52|189.79
35274176|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1908||||1908|417.37|1316.52|189.79
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AARP [1000]|AARP [100000]|2851||||2851|550|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2851||||2851|337.15|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AETNA [1015]|AETNA [101529]|2851||||2851|660|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2851||||2851|252.74|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2851||||2851|333.81|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2851||||2851|333.81|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2851||||2851|1339.97|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2851||||2851|308.34|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2851||||2851|1425.5|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2851||||2851|1796.13|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2851||||2851|252.74|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2851||||2851|333.81|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2851||||2851|600|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2851||||2851|1967.19|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2851||||2851|460.15|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2851||||2851|357.52|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2851||||2851|660|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2851||||2851|252.74|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2851||||2851|333.81|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2851||||2851|660|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2851||||2851|252.74|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2851||||2851|252.74|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2851||||2851|1967.19|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2851||||2851|252.74|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|Self-pay|Self-pay|2851||||2851|997.85|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2851||||2851|252.74|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2851||||2851|252.74|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2851||||2851|550|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2851||||2851|333.81|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2851||||2851|333.81|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2851||||2851|550|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2851||||2851|333.81|1967.19|252.74
35274177|EAP|0350 - CT SCAN-GENERAL|HC ABDOM/PELVIS W/ CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2851||||2851|667.63|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|AARP [1000]|AARP [100000]|2851||||2851|550|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2851||||2851|337.15|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|AETNA [1015]|AETNA [101529]|2851||||2851|660|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2851||||2851|252.74|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2851||||2851|333.81|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2851||||2851|333.81|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2851||||2851|1339.97|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2851||||2851|308.34|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2851||||2851|1425.5|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2851||||2851|1796.13|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2851||||2851|252.74|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2851||||2851|333.81|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2851||||2851|600|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2851||||2851|1967.19|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2851||||2851|460.15|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2851||||2851|357.52|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2851||||2851|660|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2851||||2851|252.74|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2851||||2851|333.81|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2851||||2851|660|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2851||||2851|252.74|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2851||||2851|252.74|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2851||||2851|1967.19|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2851||||2851|252.74|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|Self-pay|Self-pay|2851||||2851|997.85|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2851||||2851|252.74|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2851||||2851|252.74|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2851||||2851|550|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2851||||2851|333.81|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2851||||2851|333.81|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2851||||2851|550|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2851||||2851|333.81|1967.19|252.74
35274178|EAP|0352 - CT SCAN-BODY SCAN|HC ABDOM/PELVIS W/WO CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2851||||2851|667.63|1967.19|252.74
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|AARP [1000]|AARP [100000]|79||||79|79|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|79||||79|74.1|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|AETNA [1015]|AETNA [101529]|79||||79|79|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|79||||79|62.12|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|79||||79|73.36|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|79||||79|73.36|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|BCBS [1155]|BCBS UTHCT [115568]|79||||79|37.13|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|79||||79|75.79|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|79||||79|39.5|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|79||||79|49.77|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|79||||79|62.12|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|79||||79|73.36|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|CIGNA [1260]|CIGNA GWH [126023]|79||||79|79|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|79||||79|54.51|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|79||||79|101.13|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|79||||79|78.57|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|79||||79|79|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|79||||79|62.12|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|79||||79|73.36|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|79||||79|79|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|79||||79|62.12|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|79||||79|62.12|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|79||||79|54.51|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|79||||79|62.12|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|Self-pay|Self-pay|79||||79|27.65|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|79||||79|62.12|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|79||||79|62.12|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|79||||79|79|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|79||||79|73.36|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|79||||79|73.36|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|79||||79|79|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|79||||79|73.36|146.73|27.65
35275571|EAP|0352 - CT SCAN-BODY SCAN|HC HEART QUANT EVAL CORONRY CALCIUM W/O CONT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|79||||79|146.73|146.73|27.65
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|AARP [1000]|AARP [100000]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|AETNA [1015]|AETNA [101529]|900||||900|660|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|900||||900|252.74|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|BCBS [1155]|BCBS UTHCT [115568]|900||||900|423|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|900||||900|307.37|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|900||||900|450|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|900||||900|567|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|900||||900|252.74|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|CIGNA [1260]|CIGNA GWH [126023]|900||||900|600|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|900||||900|621|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|900||||900|223.19|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|900||||900|660|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|900||||900|252.74|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|900||||900|660|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|900||||900|252.74|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|900||||900|252.74|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|900||||900|621|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|900||||900|252.74|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|Self-pay|Self-pay|900||||900|315|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|900||||900|252.74|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|900||||900|252.74|660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|900||||900||660|223.19
35275574|EAP|0352 - CT SCAN-BODY SCAN|HC CCTA W/DYE CORARTERIES/BPGRFTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|900||||900||660|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|AARP [1000]|AARP [100000]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|AETNA [1015]|AETNA [101529]|2827||||2827|660|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2827||||2827|252.74|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|BCBS [1155]|BCBS UTHCT [115568]|2827||||2827|675|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2827||||2827|308.34|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2827||||2827|900|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2827||||2827|900|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2827||||2827|252.74|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|CIGNA [1260]|CIGNA GWH [126023]|2827||||2827|600|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2827||||2827|1950.63|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2827||||2827|223.19|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2827||||2827|660|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2827||||2827|252.74|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2827||||2827|660|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2827||||2827|252.74|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2827||||2827|252.74|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2827||||2827|1950.63|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2827||||2827|252.74|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|Self-pay|Self-pay|2827||||2827|989.45|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2827||||2827|252.74|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2827||||2827|252.74|1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2827||||2827||1950.63|223.19
35275635|EAP|0352 - CT SCAN-BODY SCAN|HC CTA ABD AORTA&BI ILIOFEM W/CONT+NONCONT IF DONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2827||||2827||1950.63|223.19
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AARP [1000]|AARP [100000]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AETNA [1015]|AETNA [101529]|0.86||||0.86|0.38|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.86||||0.86|0.25|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.86||||0.86|0.4|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.86||||0.86|0.43|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.86||||0.86|0.43|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.86||||0.86|0.54|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.86||||0.86|0.25|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.86||||0.86|0.47|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.86||||0.86|0.59|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.86||||0.86|0.43|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.86||||0.86|0.38|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.86||||0.86|0.25|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.86||||0.86|0.38|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.86||||0.86|0.25|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.86||||0.86|0.25|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.86||||0.86|0.59|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.86||||0.86|0.25|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|Self-pay|Self-pay|0.86||||0.86|0.3|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.86||||0.86|0.25|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.86||||0.86|0.25|0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.86||||0.86||0.59|0.25
3542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.86||||0.86||0.59|0.25
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|558||||558|404.48|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|558||||558||404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|558||||558|109.34|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|558||||558|165.45|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|558||||558||404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|558||||558||404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|558||||558|262.26|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|558||||558|0|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|558||||558|279|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|558||||558|351.54|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|558||||558|165.45|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|558||||558||404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|558||||558|279|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|558||||558|385.02|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|558||||558|12.88|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|558||||558||404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|558||||558|109.34|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|558||||558|165.45|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|558||||558||404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|558||||558|109.34|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|558||||558|165.45|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|558||||558|165.45|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|558||||558|385.02|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|558||||558|165.45|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|558||||558|195.3|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|558||||558|165.45|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|558||||558|165.45|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|558||||558|404.48|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|558||||558||404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|558||||558||404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|558||||558|404.48|404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|558||||558||404.48|12.88
35640|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 4 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|558||||558||404.48|12.88
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|10.84||||10.84|4.78|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.84||||10.84|3.21|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|10.84||||10.84|5.09|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.84||||10.84|5.42|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.84||||10.84|5.42|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.84||||10.84|6.83|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.84||||10.84|3.21|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|10.84||||10.84|5.96|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|10.84||||10.84|7.48|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.84||||10.84|5.42|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.84||||10.84|4.78|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.84||||10.84|3.21|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.84||||10.84|4.78|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.84||||10.84|3.21|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.84||||10.84|3.21|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|10.84||||10.84|7.48|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.84||||10.84|3.21|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|10.84||||10.84|3.79|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.84||||10.84|3.21|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.84||||10.84|3.21|7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.84||||10.84||7.48|3.21
35686|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 0.5 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.84||||10.84||7.48|3.21
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|12.67||||12.67|5.59|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.67||||12.67|3.76|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|12.67||||12.67|5.95|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.67||||12.67|6.34|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.67||||12.67|6.34|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.67||||12.67|7.98|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.67||||12.67|3.76|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|12.67||||12.67|6.97|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|12.67||||12.67|8.74|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.67||||12.67|6.34|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.67||||12.67|5.59|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.67||||12.67|3.76|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.67||||12.67|5.59|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.67||||12.67|3.76|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.67||||12.67|3.76|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|12.67||||12.67|8.74|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.67||||12.67|3.76|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|12.67||||12.67|4.43|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.67||||12.67|3.76|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.67||||12.67|3.76|8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.67||||12.67||8.74|3.76
35687|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 1 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.67||||12.67||8.74|3.76
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|20.59||||20.59|9.08|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.59||||20.59|6.1|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|20.59||||20.59|9.68|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.59||||20.59|10.3|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.59||||20.59|10.3|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.59||||20.59|12.97|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.59||||20.59|6.1|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|20.59||||20.59|11.32|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|20.59||||20.59|14.21|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.59||||20.59|10.3|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.59||||20.59|9.08|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.59||||20.59|6.1|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.59||||20.59|9.08|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.59||||20.59|6.1|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.59||||20.59|6.1|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|20.59||||20.59|14.21|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.59||||20.59|6.1|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|20.59||||20.59|7.21|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.59||||20.59|6.1|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.59||||20.59|6.1|14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.59||||20.59||14.21|6.1
35688|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 2 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.59||||20.59||14.21|6.1
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|AARP [1000]|AARP [100000]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|AETNA [1015]|AETNA [101529]|1.62||||1.62|0.71|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.62||||1.62|0.48|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.62||||1.62|0.76|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.62||||1.62|0.81|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.62||||1.62|0.81|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.62||||1.62|1.02|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.62||||1.62|0.48|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.62||||1.62|0.89|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.62||||1.62|1.12|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.62||||1.62|0.81|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.62||||1.62|0.71|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.62||||1.62|0.48|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.62||||1.62|0.71|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.62||||1.62|0.48|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.62||||1.62|0.48|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.62||||1.62|1.12|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.62||||1.62|0.48|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|Self-pay|Self-pay|1.62||||1.62|0.57|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.62||||1.62|0.48|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.62||||1.62|0.48|1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.62||||1.62||1.12|0.48
3578|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 0.5 MG TABLET|2 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.62||||1.62||1.12|0.48
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.15||||1.15|0.51|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.15||||1.15|0.34|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.15||||1.15|0.54|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.15||||1.15|0.58|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.15||||1.15|0.58|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.15||||1.15|0.72|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.15||||1.15|0.34|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.15||||1.15|0.63|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.15||||1.15|0.79|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.15||||1.15|0.58|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.15||||1.15|0.51|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.15||||1.15|0.34|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.15||||1.15|0.51|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.15||||1.15|0.34|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.15||||1.15|0.34|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.15||||1.15|0.79|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.15||||1.15|0.34|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|Self-pay|Self-pay|1.15||||1.15|0.4|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.15||||1.15|0.34|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.15||||1.15|0.34|0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.15||||1.15||0.79|0.34
3579|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.15||||1.15||0.79|0.34
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.48||||2.48|1.09|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.48||||2.48|0.74|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.48||||2.48|1.17|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.48||||2.48|1.24|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.48||||2.48|1.24|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.48||||2.48|1.56|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.48||||2.48|0.74|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.48||||2.48|1.36|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.48||||2.48|1.71|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.48||||2.48|1.24|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.48||||2.48|1.09|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.48||||2.48|0.74|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.48||||2.48|1.09|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.48||||2.48|0.74|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.48||||2.48|0.74|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.48||||2.48|1.71|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.48||||2.48|0.74|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.48||||2.48|0.87|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.48||||2.48|0.74|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.48||||2.48|0.74|1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.48||||2.48||1.71|0.74
3580|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.48||||2.48||1.71|0.74
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.57||||1.57|0.69|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.57||||1.57|0.47|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.57||||1.57|0.74|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.57||||1.57|0.79|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.57||||1.57|0.79|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.57||||1.57|0.99|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.57||||1.57|0.47|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.57||||1.57|0.86|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.57||||1.57|1.08|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.57||||1.57|0.79|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.57||||1.57|0.69|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.57||||1.57|0.47|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.57||||1.57|0.69|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.57||||1.57|0.47|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.57||||1.57|0.47|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.57||||1.57|1.08|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.57||||1.57|0.47|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|Self-pay|Self-pay|1.57||||1.57|0.55|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.57||||1.57|0.47|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.57||||1.57|0.47|1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.57||||1.57||1.08|0.47
3581|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.57||||1.57||1.08|0.47
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.83||||2.83|1.25|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.83||||2.83|0.84|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.83||||2.83|1.33|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.83||||2.83|1.42|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.83||||2.83|1.42|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.83||||2.83|1.78|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.83||||2.83|0.84|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.83||||2.83|1.56|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.83||||2.83|1.95|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.83||||2.83|1.42|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.83||||2.83|1.25|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.83||||2.83|0.84|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.83||||2.83|1.25|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.83||||2.83|0.84|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.83||||2.83|0.84|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.83||||2.83|1.95|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.83||||2.83|0.84|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.83||||2.83|0.99|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.83||||2.83|0.84|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.83||||2.83|0.84|1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.83||||2.83||1.95|0.84
3583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.83||||2.83||1.95|0.84
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|2.73||||2.73|2.38|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.73||||2.73|0.81|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|2.73||||2.73|1.28|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.73||||2.73|0|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.73||||2.73|1.37|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.73||||2.73|1.72|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.73||||2.73|0.81|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|2.73||||2.73|1.5|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.73||||2.73|1.88|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.73||||2.73|1.11|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.73||||2.73|2.38|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.73||||2.73|0.81|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.73||||2.73|2.38|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.73||||2.73|0.81|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.73||||2.73|0.81|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.73||||2.73|1.88|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.73||||2.73|0.81|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|2.73||||2.73|0.96|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.73||||2.73|0.81|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.73||||2.73|0.81|2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.73||||2.73||2.38|0.81
3584|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HALOPERIDOL LACTATE 5 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.73||||2.73||2.38|0.81
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AARP [1000]|AARP [100000]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AARP [1000]|AARP [100000]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AETNA [1015]|AETNA [101529]|0.73||||0.73|0.32|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AETNA [1015]|AETNA [101529]|0.73||||0.73|0.32|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|0.73||||0.73|0.34|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|0.73||||0.73|0.34|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.73||||0.73|0.37|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.73||||0.73|0.37|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.73||||0.73|0.37|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.73||||0.73|0.37|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.73||||0.73|0.46|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.73||||0.73|0.46|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|0.73||||0.73|0.4|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|0.73||||0.73|0.4|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.73||||0.73|0.5|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.73||||0.73|0.5|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.73||||0.73|0.37|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.73||||0.73|0.37|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.73||||0.73|0.32|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.73||||0.73|0.32|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.73||||0.73|0.32|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.73||||0.73|0.32|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.73||||0.73|0.5|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.73||||0.73|0.5|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|Self-pay|Self-pay|0.73||||0.73|0.26|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|Self-pay|Self-pay|0.73||||0.73|0.26|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.73||||0.73|0.22|0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.73||||0.73||0.5|0.22
3585|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HALOPERIDOL LACTATE 2 MG/ML ORAL CONCENTRATE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.73||||0.73||0.5|0.22
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901001|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901002|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901003|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901004|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901007|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901008|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901009|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901010|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901011|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901012|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901013|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901014|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901015|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901016|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901017|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901018|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901019|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901020|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901021|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901022|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
35901023|EAP|0359 - CT SCAN-OTHER CT SCANS|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|AARP [1000]|AARP [100000]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|AETNA [1015]|AETNA [101529]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135||||135|40.03|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|BCBS [1155]|BCBS UTHCT [115568]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135||||135|0|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135||||135|40.03|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|CIGNA [1260]|CIGNA GWH [126023]|135||||135|0|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|135||||135|86.4|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|135||||135|67.5|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135||||135|40.03|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135||||135|40.03|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|135||||135|40.03|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|135||||135|86.4|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135||||135|40.03|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|Self-pay|Self-pay|135||||135|47.25|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|135||||135|40.03|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135||||135|40.03|86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135||||135||86.4|40.03
36000259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ ARTHROGR SACROILIAC JNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135||||135||86.4|40.03
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|AARP [1000]|AARP [100000]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|AETNA [1015]|AETNA [101529]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9697.2||||9697.2|2875.22|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|BCBS [1155]|BCBS UTHCT [115568]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9697.2||||9697.2|2875.22|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|CIGNA [1260]|CIGNA GWH [126023]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9697.2||||9697.2|6206.21|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9697.2||||9697.2|5517.38|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9697.2||||9697.2|2875.22|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9697.2||||9697.2|2875.22|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|9697.2||||9697.2|2875.22|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9697.2||||9697.2|6206.21|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9697.2||||9697.2|2875.22|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|Self-pay|Self-pay|9697.2||||9697.2|3394.02|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9697.2||||9697.2|2875.22|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9697.2||||9697.2|2875.22|6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9697.2||||9697.2||6206.21|2875.22
36009739|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOSCOPY PROSTATIC IMP 1-3|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9697.2||||9697.2||6206.21|2875.22
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|AARP [1000]|AARP [100000]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|AETNA [1015]|AETNA [101529]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19876.38||||19876.38|5893.35|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|BCBS [1155]|BCBS UTHCT [115568]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19876.38||||19876.38|5893.35|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|CIGNA [1260]|CIGNA GWH [126023]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|19876.38||||19876.38|12720.88|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19876.38||||19876.38|10322.66|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19876.38||||19876.38|5893.35|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19876.38||||19876.38|5893.35|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|19876.38||||19876.38|5893.35|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|19876.38||||19876.38|12720.88|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19876.38||||19876.38|5893.35|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|Self-pay|Self-pay|19876.38||||19876.38|6956.73|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19876.38||||19876.38|5893.35|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19876.38||||19876.38|5893.35|12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19876.38||||19876.38||12720.88|5893.35
36009740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO IMPL 4 OR MORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19876.38||||19876.38||12720.88|5893.35
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AARP [1000]|AARP [100000]|1555||||1555|361|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1555||||1555|569.66|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AETNA [1015]|AETNA [101529]|1555||||1555|1555|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1555||||1555|461.06|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1555||||1555|564.02|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1555||||1555|564.02|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|BCBS [1155]|BCBS UTHCT [115568]|1555||||1555||1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1555||||1555|55.65|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1555||||1555||1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1555||||1555||1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1555||||1555|461.06|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1555||||1555|564.02|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|CIGNA [1260]|CIGNA GWH [126023]|1555||||1555||1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1555||||1555|995.2|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1555||||1555|777.46|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1555||||1555|604.06|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1555||||1555|1555|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1555||||1555|461.06|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1555||||1555|564.02|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1555||||1555|1555|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1555||||1555|461.06|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1555||||1555|461.06|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1555||||1555|995.2|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1555||||1555|461.06|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|Self-pay|Self-pay|1555||||1555|544.25|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1555||||1555|461.06|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1555||||1555|285.13|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1555||||1555|361|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1555||||1555|564.02|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1555||||1555|564.02|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1555||||1555|361|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1555||||1555|564.02|1555|55.65
36010005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1555||||1555|1128.03|1555|55.65
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|AARP [1000]|AARP [100000]|150.18||||150.18|119|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|AETNA [1015]|AETNA [101529]|150.18||||150.18|150.18|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|150.18||||150.18|44.53|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|BCBS [1155]|BCBS UTHCT [115568]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|150.18||||150.18|0|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|150.18||||150.18|44.53|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|CIGNA [1260]|CIGNA GWH [126023]|150.18||||150.18|0|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|150.18||||150.18|96.12|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|150.18||||150.18|75.09|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|150.18||||150.18|150.18|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|150.18||||150.18|44.53|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|150.18||||150.18|150.18|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|150.18||||150.18|44.53|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|150.18||||150.18|44.53|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|150.18||||150.18|96.12|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|150.18||||150.18|44.53|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|Self-pay|Self-pay|150.18||||150.18|52.56|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|150.18||||150.18|44.53|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|150.18||||150.18|44.53|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|150.18||||150.18|119|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|150.18||||150.18|119|150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|150.18||||150.18||150.18|44.53
36010006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDL ASPIRATION BX W/US GDN EA ADDL LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|150.18||||150.18||150.18|44.53
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|AARP [1000]|AARP [100000]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|AETNA [1015]|AETNA [101529]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|343.41||||343.41|101.82|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|BCBS [1155]|BCBS UTHCT [115568]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|343.41||||343.41|101.82|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|CIGNA [1260]|CIGNA GWH [126023]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|343.41||||343.41|219.78|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|343.41||||343.41|777.46|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|343.41||||343.41|101.82|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|343.41||||343.41|101.82|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|343.41||||343.41|101.82|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|343.41||||343.41|219.78|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|343.41||||343.41|101.82|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|Self-pay|Self-pay|343.41||||343.41|120.19|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|343.41||||343.41|101.82|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|343.41||||343.41|285.13|777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|343.41||||343.41||777.46|101.82
36010009|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|343.41||||343.41||777.46|101.82
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|AARP [1000]|AARP [100000]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|AETNA [1015]|AETNA [101529]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|624||||624|185.02|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|624||||624|185.02|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|624||||624|399.36|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|624||||624|432.3|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|624||||624|185.02|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|624||||624|185.02|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|624||||624|185.02|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|624||||624|399.36|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|624||||624|185.02|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|Self-pay|Self-pay|624||||624|218.4|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|624||||624|185.02|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|624||||624|285.13|432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|624||||624||432.3|185.02
36010021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FINE NDLE ASPIRATION W/O IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|624||||624||432.3|185.02
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AARP [1000]|AARP [100000]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AETNA [1015]|AETNA [101529]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|792||||792|234.83|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BCBS UTHCT [115568]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|792||||792|234.83|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|CIGNA [1260]|CIGNA GWH [126023]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|792||||792|506.88|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|792||||792|777.46|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|792||||792|234.83|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|792||||792|234.83|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|792||||792|234.83|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|792||||792|506.88|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|792||||792|234.83|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|Self-pay|Self-pay|792||||792|277.2|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|792||||792|234.83|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|792||||792|69.03|777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|792||||792||777.46|69.03
36010030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAINAGE SOFT TISSUE PERC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|792||||792||777.46|69.03
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|AARP [1000]|AARP [100000]|518||||518|119|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|518||||518|164.44|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|AETNA [1015]|AETNA [101529]|518||||518|518|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|518||||518|153.59|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|518||||518|162.82|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|518||||518|162.82|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|BCBS [1155]|BCBS UTHCT [115568]|518||||518|1350|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|518||||518|57|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|518||||518|1682|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|518||||518|1800|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|518||||518|153.59|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|518||||518|162.82|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|CIGNA [1260]|CIGNA GWH [126023]|518||||518|150|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|518||||518|331.52|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|518||||518|224.44|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|518||||518|174.38|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|518||||518|518|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|518||||518|153.59|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|518||||518|162.82|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|518||||518|518|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|518||||518|153.59|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|518||||518|153.59|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|518||||518|331.52|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|518||||518|153.59|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|Self-pay|Self-pay|518||||518|181.3|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|518||||518|153.59|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|518||||518|285.13|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|518||||518|119|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|518||||518|162.82|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|518||||518|162.82|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|518||||518|119|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|518||||518|162.82|1800|57
36010060|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS SIMP/SINGLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|518||||518|325.63|1800|57
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|AARP [1000]|AARP [100000]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|AETNA [1015]|AETNA [101529]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|551||||551|163.37|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|BCBS [1155]|BCBS UTHCT [115568]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|551||||551|163.37|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|CIGNA [1260]|CIGNA GWH [126023]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|551||||551|352.64|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|551||||551|432.3|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|551||||551|163.37|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|551||||551|163.37|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|551||||551|163.37|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|551||||551|352.64|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|551||||551|163.37|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|Self-pay|Self-pay|551||||551|192.85|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|551||||551|163.37|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|551||||551|285.13|432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|551||||551||432.3|163.37
36010061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SKIN ABSCESS COMPLICATED/MULTIPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|551||||551||432.3|163.37
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|AARP [1000]|AARP [100000]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|AETNA [1015]|AETNA [101529]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258||||258|76.5|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|BCBS [1155]|BCBS UTHCT [115568]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258||||258|76.5|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|CIGNA [1260]|CIGNA GWH [126023]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|258||||258|165.12|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258||||258|777.46|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258||||258|76.5|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258||||258|76.5|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|258||||258|76.5|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|258||||258|165.12|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258||||258|76.5|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|Self-pay|Self-pay|258||||258|90.3|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258||||258|76.5|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258||||258|258|777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258||||258||777.46|76.5
36010080|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PILONIDAL CYST SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258||||258||777.46|76.5
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|AARP [1000]|AARP [100000]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|AETNA [1015]|AETNA [101529]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|577||||577|171.08|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|BCBS [1155]|BCBS UTHCT [115568]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|577||||577|171.08|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|CIGNA [1260]|CIGNA GWH [126023]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|577||||577|369.28|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|577||||577|432.3|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|577||||577|171.08|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|577||||577|171.08|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|577||||577|171.08|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|577||||577|369.28|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|577||||577|171.08|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|Self-pay|Self-pay|577||||577|201.95|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|577||||577|171.08|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|577||||577|285.13|432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|577||||577||432.3|171.08
36010120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE SMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|577||||577||432.3|171.08
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|AARP [1000]|AARP [100000]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|AETNA [1015]|AETNA [101529]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3692||||3692|1094.68|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|BCBS [1155]|BCBS UTHCT [115568]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3692||||3692|1094.68|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|CIGNA [1260]|CIGNA GWH [126023]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3692||||3692|2362.88|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3692||||3692|1758.75|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3692||||3692|1094.68|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3692||||3692|1094.68|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3692||||3692|1094.68|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3692||||3692|2362.88|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3692||||3692|1094.68|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|Self-pay|Self-pay|3692||||3692|1292.2|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3692||||3692|1094.68|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3692||||3692|285.13|2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3692||||3692||2362.88|285.13
36010121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION/REMOVE F/B SUBCU TISSUE COMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3692||||3692||2362.88|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|AARP [1000]|AARP [100000]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|AETNA [1015]|AETNA [101529]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2589||||2589|767.64|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|BCBS [1155]|BCBS UTHCT [115568]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2589||||2589|767.64|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|CIGNA [1260]|CIGNA GWH [126023]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2589||||2589|1656.96|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2589||||2589|1758.75|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2589||||2589|767.64|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2589||||2589|767.64|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2589||||2589|767.64|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2589||||2589|1656.96|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2589||||2589|767.64|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|Self-pay|Self-pay|2589||||2589|906.15|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2589||||2589|767.64|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2589||||2589|285.13|1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2589||||2589||1758.75|285.13
36010140|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D HEMATOMA/SEROMA/FLUID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2589||||2589||1758.75|285.13
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|AARP [1000]|AARP [100000]|1056||||1056|119|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1056||||1056|316.75|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|AETNA [1015]|AETNA [101529]|1056||||1056|1056|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1056||||1056|313.1|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1056||||1056|313.62|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1056||||1056|313.62|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|BCBS [1155]|BCBS UTHCT [115568]|1056||||1056|1350|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1056||||1056|64.58|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1056||||1056|1682|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1056||||1056|1800|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1056||||1056|313.1|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1056||||1056|313.62|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|CIGNA [1260]|CIGNA GWH [126023]|1056||||1056|150|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1056||||1056|675.84|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1056||||1056|432.3|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1056||||1056|335.88|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1056||||1056|1056|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1056||||1056|313.1|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1056||||1056|313.62|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1056||||1056|1056|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1056||||1056|313.1|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1056||||1056|313.1|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1056||||1056|675.84|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1056||||1056|313.1|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|Self-pay|Self-pay|1056||||1056|369.6|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1056||||1056|313.1|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1056||||1056|285.13|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1056||||1056|119|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1056||||1056|313.62|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1056||||1056|313.62|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1056||||1056|119|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1056||||1056|313.62|1800|64.58
36010160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP ABSCSS/HEMATOMA/BULLA/CYST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1056||||1056|627.23|1800|64.58
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|AARP [1000]|AARP [100000]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|AETNA [1015]|AETNA [101529]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3667||||3667|1087.27|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|BCBS [1155]|BCBS UTHCT [115568]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3667||||3667|1087.27|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|CIGNA [1260]|CIGNA GWH [126023]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3667||||3667|2346.88|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3667||||3667|2962.51|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3667||||3667|1087.27|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3667||||3667|1087.27|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3667||||3667|1087.27|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3667||||3667|2346.88|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3667||||3667|1087.27|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|Self-pay|Self-pay|3667||||3667|1283.45|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3667||||3667|1087.27|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3667||||3667|381.79|2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3667||||3667||2962.51|381.79
36010180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D COMPLEX POSTOP WOUND INFECTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3667||||3667||2962.51|381.79
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|AARP [1000]|AARP [100000]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|AETNA [1015]|AETNA [101529]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1464||||1464|434.08|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|BCBS [1155]|BCBS UTHCT [115568]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1464||||1464|434.08|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|CIGNA [1260]|CIGNA GWH [126023]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1464||||1464|936.96|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1464||||1464|655.21|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1464||||1464|434.08|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1464||||1464|434.08|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1464||||1464|434.08|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1464||||1464|936.96|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1464||||1464|434.08|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|Self-pay|Self-pay|1464||||1464|512.4|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1464||||1464|434.08|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1464||||1464|285.13|936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1464||||1464||936.96|285.13
36011000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR SKIN 10% BODY SURFACE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1464||||1464||936.96|285.13
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|AARP [1000]|AARP [100000]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|AETNA [1015]|AETNA [101529]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|774||||774|229.49|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|BCBS [1155]|BCBS UTHCT [115568]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|774||||774|229.49|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|CIGNA [1260]|CIGNA GWH [126023]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|774||||774|495.36|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|774||||774|777.46|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|774||||774|229.49|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|774||||774|229.49|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|774||||774|229.49|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|774||||774|495.36|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|774||||774|229.49|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|Self-pay|Self-pay|774||||774|270.9|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|774||||774|229.49|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|774||||774|381.79|777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|774||||774||777.46|229.49
36011010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE/REMOVE FOREIGN MAT FX&/DISLC SKIN&SUBQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|774||||774||777.46|229.49
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|AARP [1000]|AARP [100000]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|AETNA [1015]|AETNA [101529]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2667||||2667|790.77|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|BCBS [1155]|BCBS UTHCT [115568]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2667||||2667|790.77|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|CIGNA [1260]|CIGNA GWH [126023]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2667||||2667|1706.88|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2667||||2667|432.3|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2667||||2667|790.77|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2667||||2667|790.77|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2667||||2667|790.77|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2667||||2667|1706.88|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2667||||2667|790.77|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|Self-pay|Self-pay|2667||||2667|933.45|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2667||||2667|790.77|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2667||||2667|381.79|1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2667||||2667||1706.88|381.79
36011042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ 1ST 20 SQ CM OR<|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2667||||2667||1706.88|381.79
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|AARP [1000]|AARP [100000]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|AETNA [1015]|AETNA [101529]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1224||||1224|362.92|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|BCBS [1155]|BCBS UTHCT [115568]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1224||||1224|362.92|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|CIGNA [1260]|CIGNA GWH [126023]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1224||||1224|783.36|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1224||||1224|655.21|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1224||||1224|362.92|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1224||||1224|362.92|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1224||||1224|362.92|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1224||||1224|783.36|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1224||||1224|362.92|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|Self-pay|Self-pay|1224||||1224|428.4|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1224||||1224|362.92|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1224||||1224|381.79|783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1224||||1224||783.36|362.92
36011043|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ/MUSCLE 1ST 20 SQCM<|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1224||||1224||783.36|362.92
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|AARP [1000]|AARP [100000]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|AETNA [1015]|AETNA [101529]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1692||||1692|501.68|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|BCBS [1155]|BCBS UTHCT [115568]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1692||||1692|501.68|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|CIGNA [1260]|CIGNA GWH [126023]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1692||||1692|1082.88|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1692||||1692|1758.75|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1692||||1692|501.68|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1692||||1692|501.68|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1692||||1692|501.68|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1692||||1692|1082.88|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1692||||1692|501.68|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|Self-pay|Self-pay|1692||||1692|592.2|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1692||||1692|501.68|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1692||||1692|381.79|1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1692||||1692||1758.75|381.79
36011044|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRID SUBQ/MUS/BON 1ST 20SQCM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1692||||1692||1758.75|381.79
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|AARP [1000]|AARP [100000]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|AETNA [1015]|AETNA [101529]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|382||||382|113.26|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|BCBS [1155]|BCBS UTHCT [115568]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|382||||382|0|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|382||||382|113.26|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|CIGNA [1260]|CIGNA GWH [126023]|382||||382|0|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|382||||382|244.48|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|382||||382|191|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|382||||382|113.26|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|382||||382|113.26|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|382||||382|113.26|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|382||||382|244.48|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|382||||382|113.26|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|Self-pay|Self-pay|382||||382|133.7|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|382||||382|113.26|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|382||||382|113.26|244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|382||||382||244.48|113.26
36011045|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE SUBQ EA ADDL 20 SQ CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|382||||382||244.48|113.26
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|AARP [1000]|AARP [100000]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|AETNA [1015]|AETNA [101529]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135||||135|40.03|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|BCBS [1155]|BCBS UTHCT [115568]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135||||135|40.03|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|CIGNA [1260]|CIGNA GWH [126023]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|135||||135|86.4|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|135||||135|224.44|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135||||135|40.03|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135||||135|40.03|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|135||||135|40.03|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|135||||135|86.4|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135||||135|40.03|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|Self-pay|Self-pay|135||||135|47.25|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|135||||135|40.03|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135||||135|40.03|224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135||||135||224.44|40.03
36011055|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARE/CUT BENIGN HYPERKERATOTIC LESION 1ST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135||||135||224.44|40.03
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|AARP [1000]|AARP [100000]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|AETNA [1015]|AETNA [101529]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182||||182|53.96|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|BCBS [1155]|BCBS UTHCT [115568]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182||||182|53.96|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|CIGNA [1260]|CIGNA GWH [126023]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182||||182|116.48|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|182||||182|224.44|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182||||182|53.96|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182||||182|53.96|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|182||||182|53.96|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182||||182|116.48|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182||||182|53.96|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|Self-pay|Self-pay|182||||182|63.7|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|182||||182|53.96|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182||||182|53.96|224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182||||182||224.44|53.96
36011056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 2-4 BENIGN LESIONS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182||||182||224.44|53.96
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|AARP [1000]|AARP [100000]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|AETNA [1015]|AETNA [101529]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|646.92||||646.92|191.81|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|BCBS [1155]|BCBS UTHCT [115568]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|646.92||||646.92|191.81|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|CIGNA [1260]|CIGNA GWH [126023]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|646.92||||646.92|414.03|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|646.92||||646.92|224.44|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|646.92||||646.92|191.81|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|646.92||||646.92|191.81|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|646.92||||646.92|191.81|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|646.92||||646.92|414.03|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|646.92||||646.92|191.81|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|Self-pay|Self-pay|646.92||||646.92|226.42|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|646.92||||646.92|191.81|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|646.92||||646.92|285.13|414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|646.92||||646.92||414.03|191.81
36011057|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PARING/CUT 4+ BENIGN LESIONS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|646.92||||646.92||414.03|191.81
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|AARP [1000]|AARP [100000]|129.63||||129.63|119|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129.63||||129.63|164.44|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|AETNA [1015]|AETNA [101529]|129.63||||129.63|129.63|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129.63||||129.63|38.44|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129.63||||129.63|162.82|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129.63||||129.63|162.82|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BCBS UTHCT [115568]|129.63||||129.63||325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129.63||||129.63|57.61|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129.63||||129.63||325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129.63||||129.63||325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129.63||||129.63|38.44|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129.63||||129.63|162.82|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|CIGNA [1260]|CIGNA GWH [126023]|129.63||||129.63||325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|129.63||||129.63|82.96|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|129.63||||129.63|224.44|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129.63||||129.63|174.38|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129.63||||129.63|129.63|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129.63||||129.63|38.44|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129.63||||129.63|162.82|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129.63||||129.63|129.63|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129.63||||129.63|38.44|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|129.63||||129.63|38.44|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|129.63||||129.63|82.96|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129.63||||129.63|38.44|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|Self-pay|Self-pay|129.63||||129.63|45.37|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|129.63||||129.63|38.44|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129.63||||129.63|129.63|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129.63||||129.63|119|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|129.63||||129.63|162.82|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|129.63||||129.63|162.82|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129.63||||129.63|119|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129.63||||129.63|162.82|325.63|38.44
36011102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TANGENTIAL BIOPSY SKIN SINGLE LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129.63||||129.63|325.63|325.63|38.44
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|AARP [1000]|AARP [100000]|237||||237|119|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|AETNA [1015]|AETNA [101529]|237||||237|237|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237||||237|70.27|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BCBS UTHCT [115568]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237||||237|0|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237||||237|70.27|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|CIGNA [1260]|CIGNA GWH [126023]|237||||237|0|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|237||||237|151.68|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|237||||237|118.5|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237||||237|237|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237||||237|70.27|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237||||237|237|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237||||237|70.27|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|237||||237|70.27|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|237||||237|151.68|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237||||237|70.27|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|Self-pay|Self-pay|237||||237|82.95|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|237||||237|70.27|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237||||237|70.27|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237||||237|119|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237||||237|119|237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237||||237||237|70.27
36011103|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  TANGENTIAL BIOPSY SKIN EA SEP/ADDL LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237||||237||237|70.27
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|AARP [1000]|AARP [100000]|524||||524|119|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|524||||524|316.75|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|AETNA [1015]|AETNA [101529]|524||||524|524|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|524||||524|155.37|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|524||||524|313.62|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|524||||524|313.62|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BCBS UTHCT [115568]|524||||524||627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|524||||524|70.86|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|524||||524||627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|524||||524||627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|524||||524|155.37|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|524||||524|313.62|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|CIGNA [1260]|CIGNA GWH [126023]|524||||524||627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|524||||524|335.36|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|524||||524|432.3|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|524||||524|335.88|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|524||||524|524|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|524||||524|155.37|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|524||||524|313.62|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|524||||524|524|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|524||||524|155.37|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|524||||524|155.37|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|524||||524|335.36|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|524||||524|155.37|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|Self-pay|Self-pay|524||||524|183.4|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|524||||524|155.37|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|524||||524|285.13|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|524||||524|119|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|524||||524|313.62|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|524||||524|313.62|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|524||||524|119|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|524||||524|313.62|627.23|70.86
36011104|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN SINGLE LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|524||||524|627.23|627.23|70.86
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|AARP [1000]|AARP [100000]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|AETNA [1015]|AETNA [101529]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|294||||294|87.17|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BCBS UTHCT [115568]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|294||||294|0|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|294||||294|87.17|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|CIGNA [1260]|CIGNA GWH [126023]|294||||294|0|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|294||||294|188.16|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|294||||294|147|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|294||||294|87.17|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|294||||294|87.17|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|294||||294|87.17|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|294||||294|188.16|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|294||||294|87.17|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|Self-pay|Self-pay|294||||294|102.9|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|294||||294|87.17|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|294||||294|87.17|188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|294||||294||188.16|87.17
36011105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCH BIOPSY SKIN EA SEP/ADDL LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|294||||294||188.16|87.17
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|AARP [1000]|AARP [100000]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|AETNA [1015]|AETNA [101529]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|843||||843|249.95|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BCBS UTHCT [115568]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|843||||843|249.95|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|CIGNA [1260]|CIGNA GWH [126023]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|843||||843|539.52|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|843||||843|655.21|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|843||||843|249.95|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|843||||843|249.95|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|843||||843|249.95|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|843||||843|539.52|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|843||||843|249.95|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|Self-pay|Self-pay|843||||843|295.05|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|843||||843|249.95|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|843||||843|285.13|655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|843||||843||655.21|249.95
36011106|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN SINGLE LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|843||||843||655.21|249.95
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|AARP [1000]|AARP [100000]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|AETNA [1015]|AETNA [101529]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|125||||125|37.06|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BCBS UTHCT [115568]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|125||||125|0|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|125||||125|37.06|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|CIGNA [1260]|CIGNA GWH [126023]|125||||125|0|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|125||||125|80|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|125||||125|62.5|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|125||||125|37.06|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|125||||125|37.06|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|125||||125|37.06|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|125||||125|80|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|125||||125|37.06|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|Self-pay|Self-pay|125||||125|43.75|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|125||||125|37.06|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|125||||125|37.06|80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|125||||125||80|37.06
36011107|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISIONAL BIOPSY SKIN EA SEP/ADDL LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|125||||125||80|37.06
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|AARP [1000]|AARP [100000]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|AETNA [1015]|AETNA [101529]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|335||||335|99.33|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|BCBS [1155]|BCBS UTHCT [115568]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|335||||335|99.33|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|CIGNA [1260]|CIGNA GWH [126023]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|GROUP PENSION ADMIN [1450]|GPA [145000]|335||||335|214.4|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|335||||335|224.44|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|335||||335|99.33|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|335||||335|99.33|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|335||||335|99.33|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|PHCS [1780]|PHCS MULTIPLAN [178000]|335||||335|214.4|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|335||||335|99.33|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|Self-pay|Self-pay|335||||335|117.25|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|335||||335|99.33|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|335||||335|99.33|224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|335||||335||224.44|99.33
36011200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN/FIBROCUTANEOUS TAGS <=15|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|335||||335||224.44|99.33
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|AARP [1000]|AARP [100000]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|AETNA [1015]|AETNA [101529]|98||||98|98|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|98||||98|29.06|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|BCBS [1155]|BCBS UTHCT [115568]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|98||||98|0|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|98||||98|29.06|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|CIGNA [1260]|CIGNA GWH [126023]|98||||98|0|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|98||||98|62.72|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|98||||98|49|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|98||||98|98|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|98||||98|29.06|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|98||||98|98|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|98||||98|29.06|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|98||||98|29.06|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|98||||98|62.72|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|98||||98|29.06|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|Self-pay|Self-pay|98||||98|34.3|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|98||||98|29.06|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|98||||98|29.06|98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|98||||98||98|29.06
36011201|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE SKIN TAGS EA ADDL 10 LESIONS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|98||||98||98|29.06
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|AARP [1000]|AARP [100000]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|AETNA [1015]|AETNA [101529]|195||||195|195|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|195||||195|57.82|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|BCBS [1155]|BCBS UTHCT [115568]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|195||||195|57.82|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|CIGNA [1260]|CIGNA GWH [126023]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|195||||195|124.8|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|195||||195|432.3|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|195||||195|195|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|195||||195|57.82|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|195||||195|195|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|195||||195|57.82|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|195||||195|57.82|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|195||||195|124.8|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|195||||195|57.82|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|Self-pay|Self-pay|195||||195|68.25|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|195||||195|57.82|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|195||||195|57.82|432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|195||||195||432.3|57.82
36011300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE SKIN LESION TR/ARM/LEG 0.5CM OR LESS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|195||||195||432.3|57.82
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|AARP [1000]|AARP [100000]|234||||234|119|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|234||||234|164.44|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|AETNA [1015]|AETNA [101529]|234||||234|234|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|234||||234|69.38|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|234||||234|162.82|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|234||||234|162.82|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|234||||234|1350|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|234||||234|131.78|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|234||||234|1682|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|234||||234|1800|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|234||||234|69.38|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|234||||234|162.82|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|234||||234|150|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|234||||234|149.76|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|234||||234|224.44|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|234||||234|174.38|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|234||||234|234|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|234||||234|69.38|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|234||||234|162.82|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|234||||234|234|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|234||||234|69.38|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|234||||234|69.38|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|234||||234|149.76|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|234||||234|69.38|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|Self-pay|Self-pay|234||||234|81.9|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|234||||234|69.38|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|234||||234|69.38|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|234||||234|119|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|234||||234|162.82|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|234||||234|162.82|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|234||||234|119|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|234||||234|162.82|1800|69.38
36011301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 0.6-1.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|234||||234|325.63|1800|69.38
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|AARP [1000]|AARP [100000]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|AETNA [1015]|AETNA [101529]|524||||524|524|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|524||||524|155.37|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|524||||524|155.37|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|524||||524|335.36|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|524||||524|224.44|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|524||||524|524|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|524||||524|155.37|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|524||||524|524|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|524||||524|155.37|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|524||||524|155.37|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|524||||524|335.36|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|524||||524|155.37|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|Self-pay|Self-pay|524||||524|183.4|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|524||||524|155.37|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|524||||524|155.37|524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|524||||524||524|155.37
36011302|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 1.1-2.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|524||||524||524|155.37
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|AARP [1000]|AARP [100000]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|AETNA [1015]|AETNA [101529]|195||||195|195|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|195||||195|57.82|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|BCBS [1155]|BCBS UTHCT [115568]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|195||||195|57.82|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|CIGNA [1260]|CIGNA GWH [126023]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|GROUP PENSION ADMIN [1450]|GPA [145000]|195||||195|124.8|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|195||||195|432.3|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|195||||195|195|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|195||||195|57.82|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|195||||195|195|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|195||||195|57.82|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|195||||195|57.82|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|PHCS [1780]|PHCS MULTIPLAN [178000]|195||||195|124.8|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|195||||195|57.82|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|Self-pay|Self-pay|195||||195|68.25|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|195||||195|57.82|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|195||||195|57.82|432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|195||||195||432.3|57.82
36011303|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION TR/ARM/LEG 2.0CM OR >|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|195||||195||432.3|57.82
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|AARP [1000]|AARP [100000]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|AETNA [1015]|AETNA [101529]|189||||189|189|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189|56.04|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189|56.04|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|120.96|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|224.44|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|189|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189|56.04|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|189|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189|56.04|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189|56.04|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|120.96|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189|56.04|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|Self-pay|Self-pay|189||||189|66.15|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189|56.04|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189|56.04|224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189||224.44|56.04
36011305|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.5CM <|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189||224.44|56.04
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|AARP [1000]|AARP [100000]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|AETNA [1015]|AETNA [101529]|284||||284|284|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|284||||284|84.21|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|BCBS [1155]|BCBS UTHCT [115568]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|284||||284|84.21|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|CIGNA [1260]|CIGNA GWH [126023]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|GROUP PENSION ADMIN [1450]|GPA [145000]|284||||284|181.76|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|284||||284|224.44|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|284||||284|284|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|284||||284|84.21|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|284||||284|284|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|284||||284|84.21|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|284||||284|84.21|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|PHCS [1780]|PHCS MULTIPLAN [178000]|284||||284|181.76|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|284||||284|84.21|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|Self-pay|Self-pay|284||||284|99.4|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|284||||284|84.21|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|284||||284|84.21|284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|284||||284||284|84.21
36011306|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 0.6-1.0|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|284||||284||284|84.21
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|AARP [1000]|AARP [100000]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|AETNA [1015]|AETNA [101529]|524||||524|524|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|524||||524|155.37|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|BCBS [1155]|BCBS UTHCT [115568]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|524||||524|155.37|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|CIGNA [1260]|CIGNA GWH [126023]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|GROUP PENSION ADMIN [1450]|GPA [145000]|524||||524|335.36|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|524||||524|224.44|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|524||||524|524|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|524||||524|155.37|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|524||||524|524|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|524||||524|155.37|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|524||||524|155.37|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|PHCS [1780]|PHCS MULTIPLAN [178000]|524||||524|335.36|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|524||||524|155.37|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|Self-pay|Self-pay|524||||524|183.4|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|524||||524|155.37|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|524||||524|285.13|524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|524||||524||524|155.37
36011307|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G 1.1-2.0|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|524||||524||524|155.37
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|AARP [1000]|AARP [100000]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|AETNA [1015]|AETNA [101529]|190||||190|190|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|190||||190|56.34|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|190||||190|56.34|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|190||||190|121.6|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|190||||190|432.3|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|190||||190|190|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|190||||190|56.34|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|190||||190|190|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|190||||190|56.34|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|190||||190|56.34|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|190||||190|121.6|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|190||||190|56.34|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|Self-pay|Self-pay|190||||190|66.5|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|190||||190|56.34|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|190||||190|56.34|432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|190||||190||432.3|56.34
36011308|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION SC/NK/H/FT/G >2.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|190||||190||432.3|56.34
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|AARP [1000]|AARP [100000]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|AETNA [1015]|AETNA [101529]|184||||184|184|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|184||||184|54.56|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|BCBS [1155]|BCBS UTHCT [115568]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|184||||184|54.56|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|CIGNA [1260]|CIGNA GWH [126023]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|GROUP PENSION ADMIN [1450]|GPA [145000]|184||||184|117.76|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|184||||184|224.44|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|184||||184|184|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|184||||184|54.56|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|184||||184|184|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|184||||184|54.56|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|184||||184|54.56|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|PHCS [1780]|PHCS MULTIPLAN [178000]|184||||184|117.76|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|184||||184|54.56|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|Self-pay|Self-pay|184||||184|64.4|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|184||||184|54.56|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|184||||184|184|224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|184||||184||224.44|54.56
36011310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.5CM OR <|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|184||||184||224.44|54.56
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|AARP [1000]|AARP [100000]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|AETNA [1015]|AETNA [101529]|186||||186|186|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|186||||186|55.15|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|186||||186|55.15|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|186||||186|119.04|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|186||||186|224.44|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|186||||186|186|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|186||||186|55.15|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|186||||186|186|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|186||||186|55.15|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|186||||186|55.15|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|186||||186|119.04|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|186||||186|55.15|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|Self-pay|Self-pay|186||||186|65.1|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|186||||186|55.15|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|186||||186|186|224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|186||||186||224.44|55.15
36011311|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 0.6-1.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|186||||186||224.44|55.15
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|AARP [1000]|AARP [100000]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|AETNA [1015]|AETNA [101529]|188||||188|188|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|188||||188|55.74|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|188||||188|55.74|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|188||||188|120.32|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|188||||188|432.3|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|188||||188|188|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|188||||188|55.74|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|188||||188|188|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|188||||188|55.74|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|188||||188|55.74|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|188||||188|120.32|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|188||||188|55.74|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|Self-pay|Self-pay|188||||188|65.8|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|188||||188|55.74|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|188||||188|188|432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|188||||188||432.3|55.74
36011312|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC 1.1-2.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|188||||188||432.3|55.74
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|AARP [1000]|AARP [100000]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|AETNA [1015]|AETNA [101529]|200||||200|200|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|200||||200|59.3|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|200||||200|59.3|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|200||||200|128|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|200||||200|432.3|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|200||||200|200|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|200||||200|59.3|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|200||||200|200|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|200||||200|59.3|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|200||||200|59.3|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|200||||200|128|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|200||||200|59.3|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|Self-pay|Self-pay|200||||200|70|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|200||||200|59.3|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|200||||200|200|432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|200||||200||432.3|59.3
36011313|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SHAVE LESION HEAD/MUC >2.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|200||||200||432.3|59.3
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|AARP [1000]|AARP [100000]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|AETNA [1015]|AETNA [101529]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2968||||2968|880.01|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2968||||2968|880.01|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2968||||2968|1899.52|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2968||||2968|777.46|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2968||||2968|880.01|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2968||||2968|880.01|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2968||||2968|880.01|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2968||||2968|1899.52|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2968||||2968|880.01|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|Self-pay|Self-pay|2968||||2968|1038.8|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2968||||2968|880.01|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2968||||2968|285.13|1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2968||||2968||1899.52|285.13
36011400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LESN TRK/ARM/LEG <=0.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2968||||2968||1899.52|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|AARP [1000]|AARP [100000]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|AETNA [1015]|AETNA [101529]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2814||||2814|834.35|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|BCBS [1155]|BCBS UTHCT [115568]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2814||||2814|834.35|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|CIGNA [1260]|CIGNA GWH [126023]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2814||||2814|1800.96|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2814||||2814|432.3|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2814||||2814|834.35|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2814||||2814|834.35|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2814||||2814|834.35|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2814||||2814|1800.96|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2814||||2814|834.35|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|Self-pay|Self-pay|2814||||2814|984.9|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2814||||2814|834.35|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2814||||2814|285.13|1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2814||||2814||1800.96|285.13
36011401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 0.6-1.0 CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2814||||2814||1800.96|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|AARP [1000]|AARP [100000]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|AETNA [1015]|AETNA [101529]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1452||||1452|430.52|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|BCBS [1155]|BCBS UTHCT [115568]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1452||||1452|430.52|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|CIGNA [1260]|CIGNA GWH [126023]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1452||||1452|929.28|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1452||||1452|777.46|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1452||||1452|430.52|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1452||||1452|430.52|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1452||||1452|430.52|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1452||||1452|929.28|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1452||||1452|430.52|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|Self-pay|Self-pay|1452||||1452|508.2|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1452||||1452|430.52|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1452||||1452|285.13|929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1452||||1452||929.28|285.13
36011402|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 1.1-2.0 CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1452||||1452||929.28|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|AARP [1000]|AARP [100000]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|AETNA [1015]|AETNA [101529]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2675||||2675|793.14|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|BCBS [1155]|BCBS UTHCT [115568]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2675||||2675|793.14|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|CIGNA [1260]|CIGNA GWH [126023]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2675||||2675|1712|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2675||||2675|777.46|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2675||||2675|793.14|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2675||||2675|793.14|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2675||||2675|793.14|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2675||||2675|1712|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2675||||2675|793.14|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|Self-pay|Self-pay|2675||||2675|936.25|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2675||||2675|793.14|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2675||||2675|285.13|1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2675||||2675||1712|285.13
36011403|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 2.1-3.0 CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2675||||2675||1712|285.13
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|AARP [1000]|AARP [100000]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|AETNA [1015]|AETNA [101529]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4118||||4118|1220.99|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|BCBS [1155]|BCBS UTHCT [115568]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4118||||4118|1220.99|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|CIGNA [1260]|CIGNA GWH [126023]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4118||||4118|2635.52|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4118||||4118|1758.75|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4118||||4118|1220.99|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4118||||4118|1220.99|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4118||||4118|1220.99|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4118||||4118|2635.52|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4118||||4118|1220.99|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|Self-pay|Self-pay|4118||||4118|1441.3|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4118||||4118|1220.99|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4118||||4118|381.79|2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4118||||4118||2635.52|381.79
36011406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BGN LESN TRK/ARM/LEG 4.0CM >|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4118||||4118||2635.52|381.79
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|AARP [1000]|AARP [100000]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|AETNA [1015]|AETNA [101529]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4283||||4283|1269.91|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|BCBS [1155]|BCBS UTHCT [115568]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4283||||4283|1269.91|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|CIGNA [1260]|CIGNA GWH [126023]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4283||||4283|2741.12|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4283||||4283|1758.75|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4283||||4283|1269.91|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4283||||4283|1269.91|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4283||||4283|1269.91|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4283||||4283|2741.12|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4283||||4283|1269.91|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|Self-pay|Self-pay|4283||||4283|1499.05|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4283||||4283|1269.91|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4283||||4283|285.13|2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4283||||4283||2741.12|285.13
36011420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.5CM<|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4283||||4283||2741.12|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|AARP [1000]|AARP [100000]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|AETNA [1015]|AETNA [101529]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3455||||3455|1024.41|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3455||||3455|1024.41|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3455||||3455|2211.2|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3455||||3455|777.46|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3455||||3455|1024.41|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3455||||3455|1024.41|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3455||||3455|1024.41|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3455||||3455|2211.2|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3455||||3455|1024.41|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|Self-pay|Self-pay|3455||||3455|1209.25|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3455||||3455|1024.41|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3455||||3455|285.13|2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3455||||3455||2211.2|285.13
36011421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 0.6-1.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3455||||3455||2211.2|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|AARP [1000]|AARP [100000]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|AETNA [1015]|AETNA [101529]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2635||||2635|781.28|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2635||||2635|781.28|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2635||||2635|1686.4|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2635||||2635|1758.75|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2635||||2635|781.28|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2635||||2635|781.28|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2635||||2635|781.28|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2635||||2635|1686.4|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2635||||2635|781.28|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|Self-pay|Self-pay|2635||||2635|922.25|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2635||||2635|781.28|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2635||||2635|285.13|1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2635||||2635||1758.75|285.13
36011422|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 1.1-2.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2635||||2635||1758.75|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|AARP [1000]|AARP [100000]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|AETNA [1015]|AETNA [101529]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5335||||5335|1581.83|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5335||||5335|1581.83|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5335||||5335|3414.4|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5335||||5335|1758.75|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5335||||5335|1581.83|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5335||||5335|1581.83|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5335||||5335|1581.83|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5335||||5335|3414.4|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5335||||5335|1581.83|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|Self-pay|Self-pay|5335||||5335|1867.25|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5335||||5335|1581.83|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5335||||5335|285.13|3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5335||||5335||3414.4|285.13
36011423|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC HN/FT/NK/SC/GN 2.1-3.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5335||||5335||3414.4|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|AARP [1000]|AARP [100000]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|AETNA [1015]|AETNA [101529]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1649||||1649|488.93|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|BCBS [1155]|BCBS UTHCT [115568]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1649||||1649|488.93|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|CIGNA [1260]|CIGNA GWH [126023]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1649||||1649|1055.36|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1649||||1649|777.46|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1649||||1649|488.93|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1649||||1649|488.93|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1649||||1649|488.93|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1649||||1649|1055.36|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1649||||1649|488.93|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|Self-pay|Self-pay|1649||||1649|577.15|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1649||||1649|488.93|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1649||||1649|285.13|1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1649||||1649||1055.36|285.13
36011440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.5CM<|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1649||||1649||1055.36|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|AARP [1000]|AARP [100000]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|AETNA [1015]|AETNA [101529]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1575||||1575|466.99|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1575||||1575|466.99|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1575||||1575|1008|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1575||||1575|777.46|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1575||||1575|466.99|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1575||||1575|466.99|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1575||||1575|466.99|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1575||||1575|1008|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1575||||1575|466.99|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|Self-pay|Self-pay|1575||||1575|551.25|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1575||||1575|466.99|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1575||||1575|285.13|1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1575||||1575||1008|285.13
36011441|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 0.6-1.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1575||||1575||1008|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|AARP [1000]|AARP [100000]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|AETNA [1015]|AETNA [101529]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2548||||2548|755.48|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2548||||2548|755.48|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2548||||2548|1630.72|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2548||||2548|777.46|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2548||||2548|755.48|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2548||||2548|755.48|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2548||||2548|755.48|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2548||||2548|1630.72|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2548||||2548|755.48|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|Self-pay|Self-pay|2548||||2548|891.8|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2548||||2548|755.48|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2548||||2548|285.13|1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2548||||2548||1630.72|285.13
36011442|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 1.1-2.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2548||||2548||1630.72|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|AARP [1000]|AARP [100000]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|AETNA [1015]|AETNA [101529]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4920||||4920|1458.78|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4920||||4920|1458.78|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4920||||4920|3148.8|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4920||||4920|1758.75|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4920||||4920|1458.78|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4920||||4920|1458.78|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4920||||4920|1458.78|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4920||||4920|3148.8|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4920||||4920|1458.78|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|Self-pay|Self-pay|4920||||4920|1722|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4920||||4920|1458.78|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4920||||4920|285.13|3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4920||||4920||3148.8|285.13
36011443|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC BENIGN LSN FACE/EAR 2.1-3.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4920||||4920||3148.8|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|AARP [1000]|AARP [100000]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|AETNA [1015]|AETNA [101529]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1649||||1649|488.93|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1649||||1649|488.93|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1649||||1649|1055.36|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1649||||1649|777.46|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1649||||1649|488.93|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1649||||1649|488.93|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1649||||1649|488.93|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1649||||1649|1055.36|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1649||||1649|488.93|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|Self-pay|Self-pay|1649||||1649|577.15|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1649||||1649|488.93|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1649||||1649|285.13|1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1649||||1649||1055.36|285.13
36011601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 0.6-1.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1649||||1649||1055.36|285.13
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|AARP [1000]|AARP [100000]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|AETNA [1015]|AETNA [101529]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|587||||587|174.05|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|587||||587|174.05|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|587||||587|375.68|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|587||||587|432.3|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|587||||587|174.05|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|587||||587|174.05|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|587||||587|174.05|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|587||||587|375.68|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|587||||587|174.05|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|Self-pay|Self-pay|587||||587|205.45|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|587||||587|174.05|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|587||||587|285.13|432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|587||||587||432.3|174.05
36011602|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 1.1-2.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|587||||587||432.3|174.05
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|AARP [1000]|AARP [100000]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|AETNA [1015]|AETNA [101529]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2426||||2426|719.31|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2426||||2426|719.31|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2426||||2426|1552.64|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2426||||2426|777.46|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2426||||2426|719.31|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2426||||2426|719.31|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2426||||2426|719.31|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2426||||2426|1552.64|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2426||||2426|719.31|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|Self-pay|Self-pay|2426||||2426|849.1|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2426||||2426|719.31|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2426||||2426|285.13|1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2426||||2426||1552.64|285.13
36011603|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG 2.1-3.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2426||||2426||1552.64|285.13
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|AARP [1000]|AARP [100000]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|AETNA [1015]|AETNA [101529]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1627||||1627|482.41|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|BCBS [1155]|BCBS UTHCT [115568]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1627||||1627|482.41|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|CIGNA [1260]|CIGNA GWH [126023]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1627||||1627|1041.28|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1627||||1627|777.46|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1627||||1627|482.41|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1627||||1627|482.41|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1627||||1627|482.41|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1627||||1627|1041.28|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1627||||1627|482.41|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|Self-pay|Self-pay|1627||||1627|569.45|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1627||||1627|482.41|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1627||||1627|381.79|1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1627||||1627||1041.28|381.79
36011604|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION MAL LESION TRUNK/ARM/LEG 3.1-4.0 CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1627||||1627||1041.28|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|AARP [1000]|AARP [100000]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|AETNA [1015]|AETNA [101529]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2562||||2562|759.63|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2562||||2562|759.63|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2562||||2562|1639.68|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2562||||2562|1758.75|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2562||||2562|759.63|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2562||||2562|759.63|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2562||||2562|759.63|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2562||||2562|1639.68|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2562||||2562|759.63|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|Self-pay|Self-pay|2562||||2562|896.7|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2562||||2562|759.63|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2562||||2562|381.79|1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2562||||2562||1758.75|381.79
36011606|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC LESION TRNK/EXTRM MALIG > 4.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2562||||2562||1758.75|381.79
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|AARP [1000]|AARP [100000]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|AETNA [1015]|AETNA [101529]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1554.9||||1554.9|461.03|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1554.9||||1554.9|461.03|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1554.9||||1554.9|995.14|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1554.9||||1554.9|777.46|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1554.9||||1554.9|461.03|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1554.9||||1554.9|461.03|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1554.9||||1554.9|461.03|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1554.9||||1554.9|995.14|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1554.9||||1554.9|461.03|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|Self-pay|Self-pay|1554.9||||1554.9|544.21|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1554.9||||1554.9|461.03|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1554.9||||1554.9|285.13|995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1554.9||||1554.9||995.14|285.13
36011621|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 0.6-1.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1554.9||||1554.9||995.14|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|AARP [1000]|AARP [100000]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|AETNA [1015]|AETNA [101529]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3525||||3525|1045.16|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3525||||3525|1045.16|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3525||||3525|2256|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3525||||3525|1758.75|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3525||||3525|1045.16|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3525||||3525|1045.16|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3525||||3525|1045.16|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3525||||3525|2256|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3525||||3525|1045.16|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|Self-pay|Self-pay|3525||||3525|1233.75|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3525||||3525|1045.16|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3525||||3525|285.13|2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3525||||3525||2256|285.13
36011623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC SC/NK/HN/FT/G MALIG 2.1-3.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3525||||3525||2256|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|AARP [1000]|AARP [100000]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|AETNA [1015]|AETNA [101529]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1207||||1207|357.88|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|BCBS [1155]|BCBS UTHCT [115568]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1207||||1207|357.88|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|CIGNA [1260]|CIGNA GWH [126023]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1207||||1207|772.48|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1207||||1207|777.46|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1207||||1207|357.88|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1207||||1207|357.88|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1207||||1207|357.88|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1207||||1207|772.48|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1207||||1207|357.88|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|Self-pay|Self-pay|1207||||1207|422.45|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1207||||1207|357.88|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1207||||1207|285.13|777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1207||||1207||777.46|285.13
36011640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC. MALIGNANT LESION F/E/E/N/L 0.5 CM/<|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1207||||1207||777.46|285.13
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|AARP [1000]|AARP [100000]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|AETNA [1015]|AETNA [101529]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|613||||613|181.75|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|613||||613|181.75|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|613||||613|392.32|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|613||||613|777.46|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|613||||613|181.75|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|613||||613|181.75|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|613||||613|181.75|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|613||||613|392.32|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|613||||613|181.75|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|Self-pay|Self-pay|613||||613|214.55|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|613||||613|181.75|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|613||||613|285.13|777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|613||||613||777.46|181.75
36011641|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 0.6-1.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|AARP [1000]|AARP [100000]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|AETNA [1015]|AETNA [101529]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|613||||613|181.75|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|613||||613|181.75|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|613||||613|392.32|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|613||||613|777.46|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|613||||613|181.75|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|613||||613|181.75|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|613||||613|181.75|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|613||||613|392.32|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|613||||613|181.75|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|Self-pay|Self-pay|613||||613|214.55|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|613||||613|181.75|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|613||||613|285.13|777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|613||||613||777.46|181.75
36011642|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 1.1-2.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|613||||613||777.46|181.75
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|AARP [1000]|AARP [100000]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|AETNA [1015]|AETNA [101529]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1770||||1770|524.81|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1770||||1770|524.81|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1770||||1770|1132.8|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1770||||1770|1758.75|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1770||||1770|524.81|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1770||||1770|524.81|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1770||||1770|524.81|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1770||||1770|1132.8|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1770||||1770|524.81|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|Self-pay|Self-pay|1770||||1770|619.5|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1770||||1770|524.81|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1770||||1770|285.13|1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1770||||1770||1758.75|285.13
36011643|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC FACE MALIG 2.1-3.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1770||||1770||1758.75|285.13
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|AARP [1000]|AARP [100000]|144||||144|119|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|144||||144|50.97|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|AETNA [1015]|AETNA [101529]|144||||144|144|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|144||||144|42.7|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|144||||144|50.47|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|144||||144|50.47|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|BCBS [1155]|BCBS UTHCT [115568]|144||||144|1350|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|144||||144|43.64|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|144||||144|1682|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|144||||144|1800|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|144||||144|42.7|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|144||||144|50.47|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|CIGNA [1260]|CIGNA GWH [126023]|144||||144|144|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|144||||144|92.16|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|144||||144|69.58|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|144||||144|54.05|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|144||||144|144|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|144||||144|42.7|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|144||||144|50.47|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|144||||144|144|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|144||||144|42.7|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|144||||144|42.7|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|144||||144|92.16|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|144||||144|42.7|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|Self-pay|Self-pay|144||||144|50.4|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|144||||144|42.7|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|144||||144|42.7|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|144||||144|119|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|144||||144|50.47|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|144||||144|50.47|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|144||||144|119|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|144||||144|50.47|1800|42.7
36011719|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRIM NONDYST NAIL(S) ANY NUMBER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|144||||144|100.94|1800|42.7
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|AARP [1000]|AARP [100000]|188||||188|119|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|188||||188|50.97|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|AETNA [1015]|AETNA [101529]|188||||188|188|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|188||||188|55.74|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|188||||188|50.47|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|188||||188|50.47|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|BCBS [1155]|BCBS UTHCT [115568]|188||||188|1350|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|188||||188|43.64|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|188||||188|1682|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|188||||188|1800|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|188||||188|55.74|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|188||||188|50.47|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|CIGNA [1260]|CIGNA GWH [126023]|188||||188|150|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|GROUP PENSION ADMIN [1450]|GPA [145000]|188||||188|120.32|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|188||||188|69.58|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|188||||188|54.05|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|188||||188|188|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|188||||188|55.74|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|188||||188|50.47|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|188||||188|188|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|188||||188|55.74|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|188||||188|55.74|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|PHCS [1780]|PHCS MULTIPLAN [178000]|188||||188|120.32|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|188||||188|55.74|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|Self-pay|Self-pay|188||||188|65.8|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|188||||188|55.74|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|188||||188|55.74|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|188||||188|119|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|188||||188|50.47|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|188||||188|50.47|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|188||||188|119|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|188||||188|50.47|1800|43.64
36011720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAIL(S) 1- 5|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|188||||188|100.94|1800|43.64
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|AARP [1000]|AARP [100000]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|AETNA [1015]|AETNA [101529]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|165||||165|48.92|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|BCBS [1155]|BCBS UTHCT [115568]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|165||||165|48.92|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|CIGNA [1260]|CIGNA GWH [126023]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|GROUP PENSION ADMIN [1450]|GPA [145000]|165||||165|105.6|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|165||||165|69.58|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|165||||165|48.92|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|165||||165|48.92|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|165||||165|48.92|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|PHCS [1780]|PHCS MULTIPLAN [178000]|165||||165|105.6|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|165||||165|48.92|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|Self-pay|Self-pay|165||||165|57.75|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|165||||165|48.92|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|165||||165|48.92|105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|165||||165||105.6|48.92
36011721|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBR NAILS 6+|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|165||||165||105.6|48.92
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|AARP [1000]|AARP [100000]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|AETNA [1015]|AETNA [101529]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|412||||412|122.16|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|BCBS [1155]|BCBS UTHCT [115568]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|412||||412|122.16|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|CIGNA [1260]|CIGNA GWH [126023]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|412||||412|263.68|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|412||||412|224.44|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|412||||412|122.16|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|412||||412|122.16|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|412||||412|122.16|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|412||||412|263.68|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|412||||412|122.16|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|Self-pay|Self-pay|412||||412|144.2|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|412||||412|122.16|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|412||||412|122.16|263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|412||||412||263.68|122.16
36011730|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE SIMPLE/SINGLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|412||||412||263.68|122.16
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|AARP [1000]|AARP [100000]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|AETNA [1015]|AETNA [101529]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|130||||130|38.55|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|BCBS [1155]|BCBS UTHCT [115568]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|130||||130|0|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|130||||130|38.55|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|CIGNA [1260]|CIGNA GWH [126023]|130||||130|0|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|130||||130|83.2|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|130||||130|65|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|130||||130|38.55|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|130||||130|38.55|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|130||||130|38.55|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|130||||130|83.2|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|130||||130|38.55|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|Self-pay|Self-pay|130||||130|45.5|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|130||||130|38.55|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|130||||130|38.55|83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|130||||130||83.2|38.55
36011732|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC AVULSION NAIL PLATE EACH ADDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|130||||130||83.2|38.55
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|AARP [1000]|AARP [100000]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|AETNA [1015]|AETNA [101529]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|160||||160|47.44|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|BCBS [1155]|BCBS UTHCT [115568]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|160||||160|47.44|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|CIGNA [1260]|CIGNA GWH [126023]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|160||||160|102.4|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|160||||160|139.94|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|160||||160|47.44|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|160||||160|47.44|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|160||||160|47.44|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|160||||160|102.4|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|160||||160|47.44|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|Self-pay|Self-pay|160||||160|56|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|160||||160|47.44|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|160||||160|47.44|139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|160||||160||139.94|47.44
36011740|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EVAC SUBUNGAL HEMATOMA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|160||||160||139.94|47.44
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|AARP [1000]|AARP [100000]|959||||959|119|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|959||||959|316.75|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|AETNA [1015]|AETNA [101529]|959||||959|959|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|959||||959|284.34|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|959||||959|313.62|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|959||||959|313.62|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|959||||959|1350|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|959||||959|74.97|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|959||||959|1682|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|959||||959|1800|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|959||||959|284.34|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|959||||959|313.62|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|959||||959|575|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|959||||959|613.76|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|959||||959|432.3|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|959||||959|335.88|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|959||||959|959|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|959||||959|284.34|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|959||||959|313.62|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|959||||959|959|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|959||||959|284.34|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|959||||959|284.34|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|959||||959|613.76|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|959||||959|284.34|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|Self-pay|Self-pay|959||||959|335.65|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|959||||959|284.34|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|959||||959|285.13|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|959||||959|119|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|959||||959|313.62|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|959||||959|313.62|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|959||||959|119|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|959||||959|313.62|1800|74.97
36011750|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC NAIL & MATRIX PARTIAL OR COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|959||||959|627.23|1800|74.97
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|AARP [1000]|AARP [100000]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|AETNA [1015]|AETNA [101529]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1457||||1457|432|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|BCBS [1155]|BCBS UTHCT [115568]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1457||||1457|432|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|CIGNA [1260]|CIGNA GWH [126023]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1457||||1457|932.48|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1457||||1457|655.21|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1457||||1457|432|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1457||||1457|432|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1457||||1457|432|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1457||||1457|932.48|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1457||||1457|432|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|Self-pay|Self-pay|1457||||1457|509.95|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1457||||1457|432|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1457||||1457|285.13|932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1457||||1457||932.48|285.13
36011760|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR NAIL BED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1457||||1457||932.48|285.13
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|AARP [1000]|AARP [100000]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|AETNA [1015]|AETNA [101529]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|842||||842|249.65|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|BCBS [1155]|BCBS UTHCT [115568]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|842||||842|249.65|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|CIGNA [1260]|CIGNA GWH [126023]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|842||||842|538.88|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|842||||842|432.3|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|842||||842|249.65|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|842||||842|249.65|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|842||||842|249.65|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|842||||842|538.88|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|842||||842|249.65|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|Self-pay|Self-pay|842||||842|294.7|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|842||||842|249.65|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|842||||842|249.65|538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|842||||842||538.88|249.65
36011765|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC WEDGE EXCISION SKIN NAIL FOLD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|842||||842||538.88|249.65
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|AARP [1000]|AARP [100000]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|AETNA [1015]|AETNA [101529]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|412||||412|122.16|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|BCBS [1155]|BCBS UTHCT [115568]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|412||||412|122.16|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|CIGNA [1260]|CIGNA GWH [126023]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|412||||412|263.68|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|412||||412|224.44|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|412||||412|122.16|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|412||||412|122.16|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|412||||412|122.16|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|412||||412|263.68|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|412||||412|122.16|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|Self-pay|Self-pay|412||||412|144.2|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|412||||412|122.16|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|412||||412|122.16|263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|412||||412||263.68|122.16
36011900|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT INTRALESIONAL 1-7 LESIONS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|412||||412||263.68|122.16
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|AARP [1000]|AARP [100000]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|AETNA [1015]|AETNA [101529]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|983||||983|291.46|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|BCBS [1155]|BCBS UTHCT [115568]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|983||||983|291.46|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|CIGNA [1260]|CIGNA GWH [126023]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|983||||983|629.12|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|983||||983|337.78|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|983||||983|291.46|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|983||||983|291.46|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|983||||983|291.46|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|983||||983|629.12|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|983||||983|291.46|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|Self-pay|Self-pay|983||||983|344.05|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|983||||983|291.46|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|983||||983|285.13|629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|983||||983||629.12|285.13
36011982|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL NON-BIODEGRADABLE DRUG DELIVERY IMPLANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|983||||983||629.12|285.13
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|AARP [1000]|AARP [100000]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|AETNA [1015]|AETNA [101529]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181||||181|53.67|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|BCBS [1155]|BCBS UTHCT [115568]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181||||181|53.67|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|CIGNA [1260]|CIGNA GWH [126023]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|181||||181|115.84|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|181||||181|337.78|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181||||181|53.67|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181||||181|53.67|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|181||||181|53.67|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|181||||181|115.84|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181||||181|53.67|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|Self-pay|Self-pay|181||||181|63.35|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|181||||181|53.67|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181||||181|181|337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181||||181||337.78|53.67
36011983|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL W/REINSERT NON-BIO DRUG DELIV IMPLANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181||||181||337.78|53.67
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|AARP [1000]|AARP [100000]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|AETNA [1015]|AETNA [101529]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|436||||436|129.27|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|BCBS [1155]|BCBS UTHCT [115568]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|436||||436|129.27|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|CIGNA [1260]|CIGNA GWH [126023]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|GROUP PENSION ADMIN [1450]|GPA [145000]|436||||436|279.04|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|436||||436|224.44|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|436||||436|129.27|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|436||||436|129.27|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|436||||436|129.27|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|PHCS [1780]|PHCS MULTIPLAN [178000]|436||||436|279.04|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|436||||436|129.27|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|Self-pay|Self-pay|436||||436|152.6|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|436||||436|129.27|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|436||||436|129.27|279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|436||||436||279.04|129.27
36012001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK 2.5CM <|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|436||||436||279.04|129.27
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|AARP [1000]|AARP [100000]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|AETNA [1015]|AETNA [101529]|412||||412|412|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|412||||412|122.16|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|412||||412|122.16|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|412||||412|263.68|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|412||||412|224.44|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|412||||412|412|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|412||||412|122.16|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|412||||412|412|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|412||||412|122.16|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|412||||412|122.16|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|412||||412|263.68|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|412||||412|122.16|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|Self-pay|Self-pay|412||||412|144.2|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|412||||412|122.16|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|412||||412|122.16|412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|412||||412||412|122.16
36012002|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 2.6-7.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|412||||412||412|122.16
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|AARP [1000]|AARP [100000]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|AETNA [1015]|AETNA [101529]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|419||||419|124.23|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|419||||419|124.23|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|419||||419|268.16|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|419||||419|224.44|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|419||||419|124.23|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|419||||419|124.23|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|419||||419|124.23|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|419||||419|268.16|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|419||||419|124.23|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|Self-pay|Self-pay|419||||419|146.65|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|419||||419|124.23|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|419||||419|124.23|268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|419||||419||268.16|124.23
36012004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 7.6-12.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|419||||419||268.16|124.23
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|AARP [1000]|AARP [100000]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|AETNA [1015]|AETNA [101529]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|489||||489|144.99|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|489||||489|144.99|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|489||||489|312.96|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|489||||489|432.3|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|489||||489|144.99|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|489||||489|144.99|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|489||||489|144.99|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|489||||489|312.96|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|489||||489|144.99|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|Self-pay|Self-pay|489||||489|171.15|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|489||||489|144.99|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|489||||489|381.79|432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|489||||489||432.3|144.99
36012005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 12.6-20.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|489||||489||432.3|144.99
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|AARP [1000]|AARP [100000]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|AETNA [1015]|AETNA [101529]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|401||||401|118.9|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|401||||401|118.9|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|401||||401|256.64|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|401||||401|432.3|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|401||||401|118.9|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|401||||401|118.9|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|401||||401|118.9|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|401||||401|256.64|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|401||||401|118.9|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|Self-pay|Self-pay|401||||401|140.35|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|401||||401|118.9|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|401||||401|381.79|432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|401||||401||432.3|118.9
36012006|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPR SC/NK/AX/GEN/TRNK/EXT 20.1-30.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|401||||401||432.3|118.9
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|AARP [1000]|AARP [100000]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|AETNA [1015]|AETNA [101529]|420||||420|420|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|420||||420|124.53|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|BCBS [1155]|BCBS UTHCT [115568]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|420||||420|124.53|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|CIGNA [1260]|CIGNA GWH [126023]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|GROUP PENSION ADMIN [1450]|GPA [145000]|420||||420|268.8|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|420||||420|224.44|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|420||||420|420|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|420||||420|124.53|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|420||||420|420|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|420||||420|124.53|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|420||||420|124.53|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|PHCS [1780]|PHCS MULTIPLAN [178000]|420||||420|268.8|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|420||||420|124.53|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|Self-pay|Self-pay|420||||420|147|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|420||||420|124.53|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|420||||420|124.53|420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|420||||420||420|124.53
36012011|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.5CM <|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|420||||420||420|124.53
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|AARP [1000]|AARP [100000]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|AETNA [1015]|AETNA [101529]|418||||418|418|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|418||||418|123.94|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|418||||418|123.94|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|418||||418|267.52|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|418||||418|224.44|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|418||||418|418|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|418||||418|123.94|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|418||||418|418|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|418||||418|123.94|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|418||||418|123.94|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|418||||418|267.52|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|418||||418|123.94|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|Self-pay|Self-pay|418||||418|146.3|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|418||||418|123.94|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|418||||418|123.94|418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|418||||418||418|123.94
36012013|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 2.6-5.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|418||||418||418|123.94
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|AARP [1000]|AARP [100000]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|AETNA [1015]|AETNA [101529]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|496||||496|147.06|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|496||||496|147.06|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|496||||496|317.44|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|496||||496|224.44|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|496||||496|147.06|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|496||||496|147.06|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|496||||496|147.06|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|496||||496|317.44|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|496||||496|147.06|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|Self-pay|Self-pay|496||||496|173.6|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|496||||496|147.06|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|496||||496|147.06|317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|496||||496||317.44|147.06
36012014|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 5.1-7.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|496||||496||317.44|147.06
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|AARP [1000]|AARP [100000]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|AETNA [1015]|AETNA [101529]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|417||||417|123.64|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|417||||417|123.64|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|417||||417|266.88|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|417||||417|224.44|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|417||||417|123.64|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|417||||417|123.64|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|417||||417|123.64|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|417||||417|266.88|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|417||||417|123.64|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|Self-pay|Self-pay|417||||417|145.95|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|417||||417|123.64|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|417||||417|285.13|285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|417||||417||285.13|123.64
36012015|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPL REP FACE/EAR/NOSE/MUCO 7.6-12.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|417||||417||285.13|123.64
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|AARP [1000]|AARP [100000]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|AETNA [1015]|AETNA [101529]|1343||||1343|592.26|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1343||||1343|398.2|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|BCBS [1155]|BCBS UTHCT [115568]|1343||||1343|631.21|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1343||||1343|671.5|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1343||||1343|671.5|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1343||||1343|846.09|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1343||||1343|398.2|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|CIGNA [1260]|CIGNA GWH [126023]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1343||||1343|926.67|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1343||||1343|655.21|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1343||||1343|592.26|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1343||||1343|398.2|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1343||||1343|592.26|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1343||||1343|398.2|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1343||||1343|398.2|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1343||||1343|926.67|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1343||||1343|398.2|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|Self-pay|Self-pay|1343||||1343|470.05|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1343||||1343|398.2|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1343||||1343|398.2|926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1343||||1343||926.67|398.2
36012020|EAP|0450 - EMERGENCY ROOM-GENERAL|HC SUPERFICIAL WND DEHISCENCE SIMPLE CLSR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1343||||1343||926.67|398.2
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|AARP [1000]|AARP [100000]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|AETNA [1015]|AETNA [101529]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|458||||458|135.8|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|BCBS [1155]|BCBS UTHCT [115568]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|458||||458|135.8|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|CIGNA [1260]|CIGNA GWH [126023]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|458||||458|293.12|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|458||||458|432.3|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|458||||458|135.8|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|458||||458|135.8|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|458||||458|135.8|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|458||||458|293.12|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|458||||458|135.8|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|Self-pay|Self-pay|458||||458|160.3|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|458||||458|135.8|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|458||||458|285.13|432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|458||||458||432.3|135.8
36012021|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPERFICIAL WND DEHIS SNGL CLSR W/PACK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|458||||458||432.3|135.8
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|AARP [1000]|AARP [100000]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|AETNA [1015]|AETNA [101529]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1218||||1218|361.14|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|BCBS [1155]|BCBS UTHCT [115568]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1218||||1218|361.14|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|CIGNA [1260]|CIGNA GWH [126023]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1218||||1218|779.52|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1218||||1218|432.3|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1218||||1218|361.14|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1218||||1218|361.14|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1218||||1218|361.14|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1218||||1218|779.52|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1218||||1218|361.14|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|Self-pay|Self-pay|1218||||1218|426.3|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1218||||1218|361.14|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1218||||1218|285.13|779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1218||||1218||779.52|285.13
36012031|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.5CM <|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1218||||1218||779.52|285.13
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|AARP [1000]|AARP [100000]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|AETNA [1015]|AETNA [101529]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|674||||674|199.84|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|674||||674|199.84|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|674||||674|431.36|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|674||||674|432.3|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|674||||674|199.84|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|674||||674|199.84|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|674||||674|199.84|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|674||||674|431.36|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|674||||674|199.84|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|Self-pay|Self-pay|674||||674|235.9|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|674||||674|199.84|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|674||||674|285.13|432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|674||||674||432.3|199.84
36012032|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 2.6-7.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|674||||674||432.3|199.84
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|AARP [1000]|AARP [100000]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|AETNA [1015]|AETNA [101529]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|596||||596|176.71|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|596||||596|176.71|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|596||||596|381.44|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|596||||596|432.3|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|596||||596|176.71|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|596||||596|176.71|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|596||||596|176.71|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|596||||596|381.44|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|596||||596|176.71|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|Self-pay|Self-pay|596||||596|208.6|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|596||||596|176.71|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|596||||596|381.79|432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|596||||596||432.3|176.71
36012034|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 7.6-12.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|596||||596||432.3|176.71
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|AARP [1000]|AARP [100000]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|AETNA [1015]|AETNA [101529]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1096||||1096|324.96|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1096||||1096|324.96|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1096||||1096|701.44|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1096||||1096|432.3|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1096||||1096|324.96|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1096||||1096|324.96|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1096||||1096|324.96|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1096||||1096|701.44|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1096||||1096|324.96|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|Self-pay|Self-pay|1096||||1096|383.6|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1096||||1096|324.96|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1096||||1096|381.79|701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1096||||1096||701.44|324.96
36012035|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR SCALP/TR/EXT 12.6-20.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1096||||1096||701.44|324.96
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|AARP [1000]|AARP [100000]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|AETNA [1015]|AETNA [101529]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|445||||445|131.94|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|BCBS [1155]|BCBS UTHCT [115568]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|445||||445|131.94|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|CIGNA [1260]|CIGNA GWH [126023]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|GROUP PENSION ADMIN [1450]|GPA [145000]|445||||445|284.8|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|445||||445|432.3|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|445||||445|131.94|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|445||||445|131.94|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|445||||445|131.94|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|PHCS [1780]|PHCS MULTIPLAN [178000]|445||||445|284.8|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|445||||445|131.94|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|Self-pay|Self-pay|445||||445|155.75|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|445||||445|131.94|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|445||||445|285.13|432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|445||||445||432.3|131.94
36012041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.5CM<|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|445||||445||432.3|131.94
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|AARP [1000]|AARP [100000]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|AETNA [1015]|AETNA [101529]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|813||||813|241.05|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|813||||813|241.05|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|813||||813|520.32|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|813||||813|432.3|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|813||||813|241.05|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|813||||813|241.05|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|813||||813|241.05|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|813||||813|520.32|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|813||||813|241.05|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|Self-pay|Self-pay|813||||813|284.55|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|813||||813|241.05|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|813||||813|285.13|520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|813||||813||520.32|241.05
36012042|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTERM REPR NK/H/F/G 2.6-7.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|813||||813||520.32|241.05
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|AARP [1000]|AARP [100000]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|AETNA [1015]|AETNA [101529]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|864||||864|256.18|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|BCBS [1155]|BCBS UTHCT [115568]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|864||||864|256.18|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|CIGNA [1260]|CIGNA GWH [126023]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|GROUP PENSION ADMIN [1450]|GPA [145000]|864||||864|552.96|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|864||||864|432.3|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|864||||864|256.18|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|864||||864|256.18|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|864||||864|256.18|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|PHCS [1780]|PHCS MULTIPLAN [178000]|864||||864|552.96|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|864||||864|256.18|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|Self-pay|Self-pay|864||||864|302.4|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|864||||864|256.18|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|864||||864|285.13|552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|864||||864||552.96|256.18
36012051|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.5CM <|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|AARP [1000]|AARP [100000]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|AETNA [1015]|AETNA [101529]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|864||||864|256.18|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|BCBS [1155]|BCBS UTHCT [115568]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|864||||864|256.18|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|CIGNA [1260]|CIGNA GWH [126023]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|864||||864|552.96|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|864||||864|432.3|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|864||||864|256.18|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|864||||864|256.18|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|864||||864|256.18|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|864||||864|552.96|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|864||||864|256.18|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|Self-pay|Self-pay|864||||864|302.4|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|864||||864|256.18|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|864||||864|285.13|552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|864||||864||552.96|256.18
36012052|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 2.6-5.0CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|864||||864||552.96|256.18
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|AARP [1000]|AARP [100000]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|AETNA [1015]|AETNA [101529]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|382||||382|113.26|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|382||||382|113.26|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|382||||382|244.48|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|382||||382|432.3|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|382||||382|113.26|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|382||||382|113.26|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|382||||382|113.26|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|382||||382|244.48|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|382||||382|113.26|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|Self-pay|Self-pay|382||||382|133.7|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|382||||382|113.26|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|382||||382|381.79|432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|382||||382||432.3|113.26
36012054|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTMD RPR FACE/MUC MEM 7.6-12.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|382||||382||432.3|113.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|AARP [1000]|AARP [100000]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|AETNA [1015]|AETNA [101529]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1296||||1296|384.26|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|BCBS [1155]|BCBS UTHCT [115568]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1296||||1296|384.26|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|CIGNA [1260]|CIGNA GWH [126023]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1296||||1296|829.44|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1296||||1296|655.21|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1296||||1296|384.26|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1296||||1296|384.26|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1296||||1296|384.26|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1296||||1296|829.44|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1296||||1296|384.26|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|Self-pay|Self-pay|1296||||1296|453.6|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1296||||1296|384.26|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1296||||1296|437.85|829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1296||||1296||829.44|384.26
36013101|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLX REPAIR TRUNK 2.6-7.5 CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1296||||1296||829.44|384.26
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|AARP [1000]|AARP [100000]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|AETNA [1015]|AETNA [101529]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2063||||2063|611.68|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2063||||2063|611.68|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2063||||2063|1320.32|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2063||||2063|655.21|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2063||||2063|611.68|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2063||||2063|611.68|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2063||||2063|611.68|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2063||||2063|1320.32|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2063||||2063|611.68|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|Self-pay|Self-pay|2063||||2063|722.05|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2063||||2063|611.68|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2063||||2063|437.85|1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2063||||2063||1320.32|437.85
36013121|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS 2.6-7.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2063||||2063||1320.32|437.85
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|AARP [1000]|AARP [100000]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|AETNA [1015]|AETNA [101529]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|742||||742|220|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|BCBS [1155]|BCBS UTHCT [115568]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|742||||742|0|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|742||||742|220|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|CIGNA [1260]|CIGNA GWH [126023]|742||||742|0|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|GROUP PENSION ADMIN [1450]|GPA [145000]|742||||742|474.88|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|742||||742|371|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|742||||742|220|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|742||||742|220|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|742||||742|220|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|PHCS [1780]|PHCS MULTIPLAN [178000]|742||||742|474.88|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|742||||742|220|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|Self-pay|Self-pay|742||||742|259.7|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|742||||742|220|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|742||||742|220|474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|742||||742||474.88|220
36013122|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX SCALP/ARMS/LEGS EA ADD 5CM<|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|742||||742||474.88|220
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|AARP [1000]|AARP [100000]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|AETNA [1015]|AETNA [101529]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|485||||485|143.8|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|BCBS [1155]|BCBS UTHCT [115568]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|485||||485|143.8|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|CIGNA [1260]|CIGNA GWH [126023]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|485||||485|310.4|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|485||||485|432.3|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|485||||485|143.8|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|485||||485|143.8|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|485||||485|143.8|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|485||||485|310.4|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|485||||485|143.8|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|Self-pay|Self-pay|485||||485|169.75|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|485||||485|143.8|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|485||||485|381.79|432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|485||||485||432.3|143.8
36013131|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 1.1-2.5 CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|485||||485||432.3|143.8
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|AARP [1000]|AARP [100000]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|AETNA [1015]|AETNA [101529]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1343.52||||1343.52|398.35|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|BCBS [1155]|BCBS UTHCT [115568]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1343.52||||1343.52|398.35|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|CIGNA [1260]|CIGNA GWH [126023]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1343.52||||1343.52|859.85|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1343.52||||1343.52|655.21|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1343.52||||1343.52|398.35|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1343.52||||1343.52|398.35|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1343.52||||1343.52|398.35|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1343.52||||1343.52|859.85|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1343.52||||1343.52|398.35|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|Self-pay|Self-pay|1343.52||||1343.52|470.23|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1343.52||||1343.52|398.35|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1343.52||||1343.52|437.85|859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1343.52||||1343.52||859.85|398.35
36013132|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/GEN 2.6-7.5 CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1343.52||||1343.52||859.85|398.35
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|AARP [1000]|AARP [100000]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|AETNA [1015]|AETNA [101529]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|409.59||||409.59|121.44|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|BCBS [1155]|BCBS UTHCT [115568]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|409.59||||409.59|0|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|409.59||||409.59|121.44|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|CIGNA [1260]|CIGNA GWH [126023]|409.59||||409.59|0|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|GROUP PENSION ADMIN [1450]|GPA [145000]|409.59||||409.59|262.14|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|409.59||||409.59|204.8|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|409.59||||409.59|121.44|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|409.59||||409.59|121.44|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|409.59||||409.59|121.44|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|PHCS [1780]|PHCS MULTIPLAN [178000]|409.59||||409.59|262.14|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|409.59||||409.59|121.44|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|Self-pay|Self-pay|409.59||||409.59|143.36|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|409.59||||409.59|121.44|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|409.59||||409.59|121.44|262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|409.59||||409.59||262.14|121.44
36013133|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX FACE/NECK/AX/GEN/H/F EA ADD 5CM <|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|409.59||||409.59||262.14|121.44
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|AARP [1000]|AARP [100000]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|AETNA [1015]|AETNA [101529]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1296||||1296|384.26|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|BCBS [1155]|BCBS UTHCT [115568]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1296||||1296|384.26|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|CIGNA [1260]|CIGNA GWH [126023]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1296||||1296|829.44|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1296||||1296|655.21|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1296||||1296|384.26|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1296||||1296|384.26|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1296||||1296|384.26|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1296||||1296|829.44|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1296||||1296|384.26|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|Self-pay|Self-pay|1296||||1296|453.6|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1296||||1296|384.26|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1296||||1296|437.85|829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1296||||1296||829.44|384.26
36013152|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REP CMPLX EYELID/NOSE/EAR/LIP 2.6-7.5 CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1296||||1296||829.44|384.26
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|AARP [1000]|AARP [100000]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|AETNA [1015]|AETNA [101529]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|602||||602|178.49|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|BCBS [1155]|BCBS UTHCT [115568]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|602||||602|0|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|602||||602|178.49|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|CIGNA [1260]|CIGNA GWH [126023]|602||||602|0|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|602||||602|385.28|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|602||||602|301|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|602||||602|178.49|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|602||||602|178.49|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|602||||602|178.49|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|602||||602|385.28|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|602||||602|178.49|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|Self-pay|Self-pay|602||||602|210.7|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|602||||602|178.49|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|602||||602|178.49|385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|602||||602||385.28|178.49
36015274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SKN SUB-GRFT T/A/L EA ADD 100SQCM PED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|602||||602||385.28|178.49
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|AARP [1000]|AARP [100000]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|AETNA [1015]|AETNA [101529]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|337||||337|99.92|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|BCBS [1155]|BCBS UTHCT [115568]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|337||||337|99.92|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|CIGNA [1260]|CIGNA GWH [126023]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|337||||337|215.68|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|337||||337|224.44|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|337||||337|99.92|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|337||||337|99.92|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|337||||337|99.92|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|337||||337|215.68|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|337||||337|99.92|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|Self-pay|Self-pay|337||||337|117.95|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|337||||337|99.92|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|337||||337|99.92|224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|337||||337||224.44|99.92
36016020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS<5% SM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|337||||337||224.44|99.92
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|AARP [1000]|AARP [100000]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|AETNA [1015]|AETNA [101529]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|468||||468|138.76|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|BCBS [1155]|BCBS UTHCT [115568]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|468||||468|138.76|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|CIGNA [1260]|CIGNA GWH [126023]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|GROUP PENSION ADMIN [1450]|GPA [145000]|468||||468|299.52|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|468||||468|224.44|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|468||||468|138.76|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|468||||468|138.76|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|468||||468|138.76|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|PHCS [1780]|PHCS MULTIPLAN [178000]|468||||468|299.52|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|468||||468|138.76|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|Self-pay|Self-pay|468||||468|163.8|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|468||||468|138.76|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|468||||468|285.13|299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|468||||468||299.52|138.76
36016025|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BURN DRESS/DEBRIDE PRTL THICKNESS 5-10% M|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|468||||468||299.52|138.76
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|AARP [1000]|AARP [100000]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|AETNA [1015]|AETNA [101529]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|524||||524|155.37|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|BCBS [1155]|BCBS UTHCT [115568]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|524||||524|155.37|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|CIGNA [1260]|CIGNA GWH [126023]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|524||||524|335.36|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|524||||524|224.44|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|524||||524|155.37|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|524||||524|155.37|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|524||||524|155.37|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|524||||524|335.36|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|524||||524|155.37|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|Self-pay|Self-pay|524||||524|183.4|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|524||||524|155.37|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|524||||524|155.37|335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|524||||524||335.36|155.37
36017000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 1ST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|AARP [1000]|AARP [100000]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|AETNA [1015]|AETNA [101529]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|524||||524|155.37|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|BCBS [1155]|BCBS UTHCT [115568]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|524||||524|0|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|524||||524|155.37|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|CIGNA [1260]|CIGNA GWH [126023]|524||||524|0|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|GROUP PENSION ADMIN [1450]|GPA [145000]|524||||524|335.36|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|524||||524|262|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|524||||524|155.37|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|524||||524|155.37|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|524||||524|155.37|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|PHCS [1780]|PHCS MULTIPLAN [178000]|524||||524|335.36|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|524||||524|155.37|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|Self-pay|Self-pay|524||||524|183.4|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|524||||524|155.37|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|524||||524|155.37|335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|524||||524||335.36|155.37
36017003|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION 2-14|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|524||||524||335.36|155.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|AARP [1000]|AARP [100000]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|AETNA [1015]|AETNA [101529]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|379||||379|112.37|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|BCBS [1155]|BCBS UTHCT [115568]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|379||||379|112.37|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|CIGNA [1260]|CIGNA GWH [126023]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|GROUP PENSION ADMIN [1450]|GPA [145000]|379||||379|242.56|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|379||||379|432.3|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|379||||379|112.37|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|379||||379|112.37|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|379||||379|112.37|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|PHCS [1780]|PHCS MULTIPLAN [178000]|379||||379|242.56|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|379||||379|112.37|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|Self-pay|Self-pay|379||||379|132.65|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|379||||379|112.37|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|379||||379|285.13|432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|379||||379||432.3|112.37
36017004|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PREMALIG LESION >15|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|379||||379||432.3|112.37
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|AARP [1000]|AARP [100000]|1003||||1003|119|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1003||||1003|164.44|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|AETNA [1015]|AETNA [101529]|1003||||1003|1003|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1003||||1003|297.39|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1003||||1003|162.82|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1003||||1003|162.82|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|BCBS [1155]|BCBS UTHCT [115568]|1003||||1003|1350|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1003||||1003|131.78|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1003||||1003|1682|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1003||||1003|1800|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1003||||1003|297.39|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1003||||1003|162.82|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|CIGNA [1260]|CIGNA GWH [126023]|1003||||1003|150|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1003||||1003|641.92|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1003||||1003|224.44|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1003||||1003|174.38|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1003||||1003|1003|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1003||||1003|297.39|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1003||||1003|162.82|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1003||||1003|1003|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1003||||1003|297.39|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1003||||1003|297.39|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1003||||1003|641.92|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1003||||1003|297.39|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|Self-pay|Self-pay|1003||||1003|351.05|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1003||||1003|297.39|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1003||||1003|297.39|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1003||||1003|119|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1003||||1003|162.82|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1003||||1003|162.82|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1003||||1003|119|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1003||||1003|162.82|1800|119
36017110|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION UP TO 14|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1003||||1003|325.63|1800|119
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|AARP [1000]|AARP [100000]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|AETNA [1015]|AETNA [101529]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|64.04|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|64.04|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|138.24|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|224.44|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|64.04|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|64.04|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|64.04|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|138.24|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|64.04|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|Self-pay|Self-pay|216||||216|75.6|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|64.04|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|64.04|224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216||224.44|64.04
36017111|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT BENIGN LESION >15|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216||224.44|64.04
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|AARP [1000]|AARP [100000]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|AETNA [1015]|AETNA [101529]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|524||||524|155.37|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|BCBS [1155]|BCBS UTHCT [115568]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|524||||524|155.37|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|CIGNA [1260]|CIGNA GWH [126023]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|524||||524|335.36|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|524||||524|224.44|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|524||||524|155.37|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|524||||524|155.37|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|524||||524|155.37|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|524||||524|335.36|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|524||||524|155.37|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|Self-pay|Self-pay|524||||524|183.4|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|524||||524|155.37|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|524||||524|155.37|335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|524||||524||335.36|155.37
36017250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CAUTERY CHEMICAL-GRANUL TISSUE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|524||||524||335.36|155.37
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|AARP [1000]|AARP [100000]|544||||544|361|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|544||||544|569.66|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|AETNA [1015]|AETNA [101529]|544||||544|544|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|544||||544|161.3|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|544||||544|564.02|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|544||||544|564.02|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|BCBS [1155]|BCBS UTHCT [115568]|544||||544|1350|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|544||||544|63.18|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|544||||544|1682|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|544||||544|1800|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|544||||544|161.3|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|544||||544|564.02|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|CIGNA [1260]|CIGNA GWH [126023]|544||||544|544|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|544||||544|348.16|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|544||||544|777.46|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|544||||544|604.06|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|544||||544|544|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|544||||544|161.3|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|544||||544|564.02|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|544||||544|544|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|544||||544|161.3|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|544||||544|161.3|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|544||||544|348.16|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|544||||544|161.3|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|Self-pay|Self-pay|544||||544|190.4|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|544||||544|161.3|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|544||||544|285.13|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|544||||544|361|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|544||||544|564.02|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|544||||544|564.02|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|544||||544|361|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|544||||544|564.02|1800|63.18
36019000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|544||||544|1128.03|1800|63.18
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|AARP [1000]|AARP [100000]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|AETNA [1015]|AETNA [101529]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|284||||284|84.21|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|BCBS [1155]|BCBS UTHCT [115568]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|284||||284|0|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|284||||284|84.21|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|CIGNA [1260]|CIGNA GWH [126023]|284||||284|0|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|284||||284|181.76|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|284||||284|142|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|284||||284|84.21|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|284||||284|84.21|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|284||||284|84.21|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|284||||284|181.76|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|284||||284|84.21|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|Self-pay|Self-pay|284||||284|99.4|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|284||||284|84.21|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|284||||284|84.21|181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|284||||284||181.76|84.21
36019001|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE ASPIRATION BREAST CYST EA ADDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|284||||284||181.76|84.21
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|AARP [1000]|AARP [100000]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|AETNA [1015]|AETNA [101529]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3283||||3283|973.41|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|BCBS [1155]|BCBS UTHCT [115568]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3283||||3283|973.41|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|CIGNA [1260]|CIGNA GWH [126023]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3283||||3283|2101.12|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3283||||3283|1758.75|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3283||||3283|973.41|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3283||||3283|973.41|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3283||||3283|973.41|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3283||||3283|2101.12|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3283||||3283|973.41|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|Self-pay|Self-pay|3283||||3283|1149.05|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3283||||3283|973.41|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3283||||3283|381.79|2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3283||||3283||2101.12|381.79
36019020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MASTOTOMY W/EXPLOR & DRAIN ABSCESS BRST DEEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3283||||3283||2101.12|381.79
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|AARP [1000]|AARP [100000]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|AETNA [1015]|AETNA [101529]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|628||||628|186.2|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|BCBS [1155]|BCBS UTHCT [115568]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|628||||628|0|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|628||||628|186.2|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|CIGNA [1260]|CIGNA GWH [126023]|628||||628|0|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|628||||628|401.92|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|628||||628|314|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|628||||628|186.2|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|628||||628|186.2|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|628||||628|186.2|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|628||||628|401.92|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|628||||628|186.2|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|Self-pay|Self-pay|628||||628|219.8|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|628||||628|186.2|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|628||||628|186.2|401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|628||||628||401.92|186.2
36019030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ MAMMORY/DUCTOGRAM/GALACTOGRAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|628||||628||401.92|186.2
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|AARP [1000]|AARP [100000]|1939||||1939|130|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1939||||1939|1288.66|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|AETNA [1015]|AETNA [101529]|1939||||1939|855.1|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1939||||1939|574.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1939||||1939|1275.9|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1939||||1939|1275.9|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|BCBS [1155]|BCBS UTHCT [115568]|1939||||1939|911.33|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1939||||1939|969.5|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1939||||1939|969.5|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1939||||1939|1221.57|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1939||||1939|574.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1939||||1939|1275.9|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|CIGNA [1260]|CIGNA GWH [126023]|1939||||1939|975|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1939||||1939|1337.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1939||||1939|1758.75|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1939||||1939|1366.49|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1939||||1939|855.1|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1939||||1939|574.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1939||||1939|1275.9|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1939||||1939|855.1|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1939||||1939|574.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1939||||1939|574.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1939||||1939|1337.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1939||||1939|574.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|Self-pay|Self-pay|1939||||1939|678.65|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1939||||1939|574.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1939||||1939|574.91|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1939||||1939|130|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1939||||1939|1275.9|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1939||||1939|1275.9|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1939||||1939|130|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1939||||1939|1275.9|2551.8|130
36019081|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE 1ST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1939||||1939|2551.8|2551.8|130
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|AARP [1000]|AARP [100000]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|AETNA [1015]|AETNA [101529]|194||||194|85.55|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|194||||194|57.52|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|BCBS [1155]|BCBS UTHCT [115568]|194||||194|91.18|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|194||||194|0|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|194||||194|97|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|194||||194|122.22|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|194||||194|57.52|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|CIGNA [1260]|CIGNA GWH [126023]|194||||194|106.7|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|194||||194|133.86|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|194||||194|97|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|194||||194|85.55|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|194||||194|57.52|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|194||||194|85.55|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|194||||194|57.52|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|194||||194|57.52|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|194||||194|133.86|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|194||||194|57.52|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|Self-pay|Self-pay|194||||194|67.9|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|194||||194|57.52|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|194||||194|57.52|133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|194||||194||133.86|57.52
36019082|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC BX BREAST LESION W/STEREOTACTIC GUIDE EA ADD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|194||||194||133.86|57.52
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|AARP [1000]|AARP [100000]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|AETNA [1015]|AETNA [101529]|1939||||1939|855.1|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1939||||1939|574.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|BCBS [1155]|BCBS UTHCT [115568]|1939||||1939|911.33|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1939||||1939|1396.08|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1939||||1939|969.5|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1939||||1939|1221.57|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1939||||1939|574.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|CIGNA [1260]|CIGNA GWH [126023]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1939||||1939|1337.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1939||||1939|1758.75|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1939||||1939|855.1|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1939||||1939|574.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1939||||1939|855.1|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1939||||1939|574.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1939||||1939|574.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1939||||1939|1337.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1939||||1939|574.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|Self-pay|Self-pay|1939||||1939|678.65|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1939||||1939|574.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1939||||1939|574.91|1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1939||||1939||1758.75|574.91
36019083|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE 1ST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1939||||1939||1758.75|574.91
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|AARP [1000]|AARP [100000]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|AETNA [1015]|AETNA [101529]|182||||182|80.26|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182||||182|53.96|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|BCBS [1155]|BCBS UTHCT [115568]|182||||182|85.54|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182||||182|0|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182||||182|91|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182||||182|114.66|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182||||182|53.96|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|CIGNA [1260]|CIGNA GWH [126023]|182||||182|100.1|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182||||182|125.58|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|182||||182|91|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182||||182|80.26|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182||||182|53.96|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182||||182|80.26|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182||||182|53.96|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|182||||182|53.96|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182||||182|125.58|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182||||182|53.96|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|Self-pay|Self-pay|182||||182|63.7|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|182||||182|53.96|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182||||182|53.96|125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182||||182||125.58|53.96
36019084|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BX BREAST LESION W/ULTRASOUND GUIDE EA ADD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182||||182||125.58|53.96
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|AARP [1000]|AARP [100000]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|AETNA [1015]|AETNA [101529]|1939||||1939|880|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1939||||1939|574.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|BCBS [1155]|BCBS UTHCT [115568]|1939||||1939|911.33|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1939||||1939|969.5|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1939||||1939|969.5|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1939||||1939|1221.57|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1939||||1939|574.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|CIGNA [1260]|CIGNA GWH [126023]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1939||||1939|1337.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1939||||1939|1758.75|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1939||||1939|880|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1939||||1939|574.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1939||||1939|880|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1939||||1939|574.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1939||||1939|574.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1939||||1939|1337.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1939||||1939|574.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|Self-pay|Self-pay|1939||||1939|678.65|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1939||||1939|574.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1939||||1939|574.91|1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1939||||1939||1758.75|574.91
36019085|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BX BREAST LESION W/MAGNETIC RESONANCE GUIDE 1ST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1939||||1939||1758.75|574.91
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|AARP [1000]|AARP [100000]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|AETNA [1015]|AETNA [101529]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3710||||3710|1100.02|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3710||||3710|1100.02|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3710||||3710|2374.4|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3710||||3710|1758.75|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3710||||3710|1100.02|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3710||||3710|1100.02|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3710||||3710|1100.02|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3710||||3710|2374.4|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3710||||3710|1100.02|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|Self-pay|Self-pay|3710||||3710|1298.5|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3710||||3710|1100.02|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3710||||3710|285.13|2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3710||||3710||2374.4|285.13
36019100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY BREAST NEEDLE W/O IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3710||||3710||2374.4|285.13
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|AARP [1000]|AARP [100000]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|AETNA [1015]|AETNA [101529]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5106||||5106|1513.93|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|BCBS [1155]|BCBS UTHCT [115568]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5106||||5106|1513.93|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|CIGNA [1260]|CIGNA GWH [126023]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5106||||5106|3267.84|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5106||||5106|3947.18|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5106||||5106|1513.93|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5106||||5106|1513.93|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5106||||5106|1513.93|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5106||||5106|3267.84|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5106||||5106|1513.93|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|Self-pay|Self-pay|5106||||5106|1787.1|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5106||||5106|1513.93|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5106||||5106|437.85|3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5106||||5106||3947.18|437.85
36019120|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC CYST/FIBROID/TUMOR/LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5106||||5106||3947.18|437.85
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|AARP [1000]|AARP [100000]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|AETNA [1015]|AETNA [101529]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|271||||271|80.35|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|BCBS [1155]|BCBS UTHCT [115568]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|271||||271|80.35|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|CIGNA [1260]|CIGNA GWH [126023]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|271||||271|173.44|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|271||||271|777.46|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|271||||271|80.35|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|271||||271|80.35|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|271||||271|80.35|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|271||||271|173.44|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|271||||271|80.35|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|Self-pay|Self-pay|271||||271|94.85|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|271||||271|80.35|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|271||||271|80.35|777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|271||||271||777.46|80.35
36019281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING 1ST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|271||||271||777.46|80.35
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|AARP [1000]|AARP [100000]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|AETNA [1015]|AETNA [101529]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|110||||110|32.62|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|BCBS [1155]|BCBS UTHCT [115568]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|110||||110|0|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|110||||110|32.62|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|CIGNA [1260]|CIGNA GWH [126023]|110||||110|0|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|110||||110|70.4|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|110||||110|55|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|110||||110|32.62|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|110||||110|32.62|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|110||||110|32.62|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|110||||110|70.4|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|110||||110|32.62|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|Self-pay|Self-pay|110||||110|38.5|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|110||||110|32.62|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|110||||110|32.62|70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|110||||110||70.4|32.62
36019282|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEVICE BREAST W/ MG IMAGING ADDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|110||||110||70.4|32.62
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|AARP [1000]|AARP [100000]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|AETNA [1015]|AETNA [101529]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|271||||271|80.35|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|BCBS [1155]|BCBS UTHCT [115568]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|271||||271|80.35|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|CIGNA [1260]|CIGNA GWH [126023]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|271||||271|173.44|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|271||||271|777.46|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|271||||271|80.35|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|271||||271|80.35|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|271||||271|80.35|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|271||||271|173.44|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|271||||271|80.35|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|Self-pay|Self-pay|271||||271|94.85|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|271||||271|80.35|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|271||||271|80.35|777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|271||||271||777.46|80.35
36019285|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DEV BREAST W/US GUIDE 1ST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|271||||271||777.46|80.35
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AARP [1000]|AARP [100000]|3710||||3710|567|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3710||||3710|1288.66|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AETNA [1015]|AETNA [101529]|3710||||3710|2200|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3710||||3710|1100.02|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3710||||3710|1275.9|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3710||||3710|1275.9|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS [1155]|BCBS UTHCT [115568]|3710||||3710|667|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3710||||3710|1051.46|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3710||||3710|889|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3710||||3710|889|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3710||||3710|1100.02|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3710||||3710|1275.9|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|CIGNA [1260]|CIGNA GWH [126023]|3710||||3710|575|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3710||||3710|2374.4|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3710||||3710|1758.75|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3710||||3710|1366.49|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3710||||3710|2200|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3710||||3710|1100.02|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3710||||3710|1275.9|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3710||||3710|2200|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3710||||3710|1100.02|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3710||||3710|1100.02|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3710||||3710|2374.4|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3710||||3710|1100.02|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|Self-pay|Self-pay|3710||||3710|1298.5|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3710||||3710|1100.02|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3710||||3710|285.13|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3710||||3710|567|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3710||||3710|1275.9|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3710||||3710|1275.9|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3710||||3710|567|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3710||||3710|1275.9|2551.8|285.13
36020206|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC NEEDLE BIOPSY MUSCLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3710||||3710|2551.8|2551.8|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|AARP [1000]|AARP [100000]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|AETNA [1015]|AETNA [101529]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1284||||1284|380.71|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|BCBS [1155]|BCBS UTHCT [115568]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1284||||1284|380.71|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|CIGNA [1260]|CIGNA GWH [126023]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1284||||1284|821.76|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1284||||1284|1758.75|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1284||||1284|380.71|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1284||||1284|380.71|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1284||||1284|380.71|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1284||||1284|821.76|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1284||||1284|380.71|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|Self-pay|Self-pay|1284||||1284|449.4|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1284||||1284|380.71|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1284||||1284|285.13|1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1284||||1284||1758.75|285.13
36020220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE SUPERFICIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1284||||1284||1758.75|285.13
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|AARP [1000]|AARP [100000]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|AETNA [1015]|AETNA [101529]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2283||||2283|676.91|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|BCBS [1155]|BCBS UTHCT [115568]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2283||||2283|676.91|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|CIGNA [1260]|CIGNA GWH [126023]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2283||||2283|1461.12|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2283||||2283|1758.75|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2283||||2283|676.91|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2283||||2283|676.91|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2283||||2283|676.91|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2283||||2283|1461.12|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2283||||2283|676.91|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|Self-pay|Self-pay|2283||||2283|799.05|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2283||||2283|676.91|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2283||||2283|381.79|1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2283||||2283||1758.75|381.79
36020225|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX BONE TROCAR/NEEDLE DEEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2283||||2283||1758.75|381.79
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|AARP [1000]|AARP [100000]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|AETNA [1015]|AETNA [101529]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|446||||446|132.24|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|BCBS [1155]|BCBS UTHCT [115568]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|446||||446|0|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|446||||446|132.24|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|CIGNA [1260]|CIGNA GWH [126023]|446||||446|0|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|446||||446|285.44|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|446||||446|223|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|446||||446|132.24|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|446||||446|132.24|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|446||||446|132.24|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|446||||446|285.44|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|446||||446|132.24|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|Self-pay|Self-pay|446||||446|156.1|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|446||||446|132.24|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|446||||446|132.24|285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|446||||446||285.44|132.24
36020501|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINUS TRACT/DX SINOGRAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|446||||446||285.44|132.24
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|AARP [1000]|AARP [100000]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|AETNA [1015]|AETNA [101529]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|707||||707|209.63|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|BCBS [1155]|BCBS UTHCT [115568]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|707||||707|209.63|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|CIGNA [1260]|CIGNA GWH [126023]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|707||||707|452.48|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|707||||707|326.46|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|707||||707|209.63|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|707||||707|209.63|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|707||||707|209.63|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|707||||707|452.48|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|707||||707|209.63|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|Self-pay|Self-pay|707||||707|247.45|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|707||||707|209.63|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|707||||707|285.13|452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|707||||707||452.48|209.63
36020526|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TX CARPAL TUNNEL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|707||||707||452.48|209.63
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|AARP [1000]|AARP [100000]|745||||745|119|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|745||||745|239.2|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|AETNA [1015]|AETNA [101529]|745||||745|745|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|745||||745|220.89|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|745||||745|236.83|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|745||||745|236.83|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|BCBS [1155]|BCBS UTHCT [115568]|745||||745|1350|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|745||||745|18.81|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|745||||745|1682|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|745||||745|1800|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|745||||745|220.89|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|745||||745|236.83|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|CIGNA [1260]|CIGNA GWH [126023]|745||||745|575|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|745||||745|476.8|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|745||||745|326.46|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|745||||745|253.65|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|745||||745|745|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|745||||745|220.89|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|745||||745|236.83|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|745||||745|745|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|745||||745|220.89|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|745||||745|220.89|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|745||||745|476.8|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|745||||745|220.89|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|Self-pay|Self-pay|745||||745|260.75|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|745||||745|220.89|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|745||||745|285.13|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|745||||745|119|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|745||||745|236.83|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|745||||745|236.83|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|745||||745|119|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|745||||745|236.83|1800|18.81
36020550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ TENDON SHEATH/LIGAMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|745||||745|473.66|1800|18.81
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|AARP [1000]|AARP [100000]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|AETNA [1015]|AETNA [101529]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|335||||335|99.33|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|BCBS [1155]|BCBS UTHCT [115568]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|335||||335|99.33|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|CIGNA [1260]|CIGNA GWH [126023]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|335||||335|214.4|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|335||||335|326.46|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|335||||335|99.33|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|335||||335|99.33|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|335||||335|99.33|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|335||||335|214.4|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|335||||335|99.33|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|Self-pay|Self-pay|335||||335|117.25|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|335||||335|99.33|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|335||||335|285.13|326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|335||||335||326.46|99.33
36020551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SINGLE TENDON ORIGIN/INSERTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|335||||335||326.46|99.33
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|AARP [1000]|AARP [100000]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|AETNA [1015]|AETNA [101529]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|785||||785|232.75|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|BCBS [1155]|BCBS UTHCT [115568]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|785||||785|232.75|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|CIGNA [1260]|CIGNA GWH [126023]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|785||||785|502.4|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|785||||785|326.46|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|785||||785|232.75|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|785||||785|232.75|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|785||||785|232.75|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|785||||785|502.4|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|785||||785|232.75|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|Self-pay|Self-pay|785||||785|274.75|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|785||||785|232.75|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|785||||785|285.13|502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|785||||785||502.4|232.75
36020552|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 1 OR 2 MUSCLE(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|785||||785||502.4|232.75
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|AARP [1000]|AARP [100000]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|AETNA [1015]|AETNA [101529]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|591||||591|175.23|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|BCBS [1155]|BCBS UTHCT [115568]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|591||||591|175.23|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|CIGNA [1260]|CIGNA GWH [126023]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|591||||591|378.24|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|591||||591|326.46|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|591||||591|175.23|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|591||||591|175.23|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|591||||591|175.23|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|591||||591|378.24|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|591||||591|175.23|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|Self-pay|Self-pay|591||||591|206.85|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|591||||591|175.23|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|591||||591|285.13|378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|591||||591||378.24|175.23
36020553|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ SNGL/MULT TRIGGER POINT 3+ MUSCLES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|591||||591||378.24|175.23
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|AARP [1000]|AARP [100000]|528||||528|119|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|528||||528|239.2|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|AETNA [1015]|AETNA [101529]|528||||528|528|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528||||528|156.55|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528||||528|236.83|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|528||||528|236.83|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|BCBS [1155]|BCBS UTHCT [115568]|528||||528|1350|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|528||||528|17.97|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|528||||528|1682|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|528||||528|1800|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|528||||528|156.55|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|528||||528|236.83|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|CIGNA [1260]|CIGNA GWH [126023]|528||||528|528|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|GROUP PENSION ADMIN [1450]|GPA [145000]|528||||528|337.92|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|528||||528|326.46|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|528||||528|253.65|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528||||528|528|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528||||528|156.55|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528||||528|236.83|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528||||528|528|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|528||||528|156.55|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|528||||528|156.55|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|PHCS [1780]|PHCS MULTIPLAN [178000]|528||||528|337.92|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528||||528|156.55|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|Self-pay|Self-pay|528||||528|184.8|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|528||||528|156.55|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|528||||528|285.13|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528||||528|119|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|528||||528|236.83|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|528||||528|236.83|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528||||528|119|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528||||528|236.83|1800|17.97
36020600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ SMALL JOINT W/O US|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|528||||528|473.66|1800|17.97
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|AARP [1000]|AARP [100000]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|AETNA [1015]|AETNA [101529]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|785||||785|232.75|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|BCBS [1155]|BCBS UTHCT [115568]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|785||||785|232.75|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|CIGNA [1260]|CIGNA GWH [126023]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|GROUP PENSION ADMIN [1450]|GPA [145000]|785||||785|502.4|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|785||||785|326.46|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|785||||785|232.75|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|785||||785|232.75|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|785||||785|232.75|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|PHCS [1780]|PHCS MULTIPLAN [178000]|785||||785|502.4|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|785||||785|232.75|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|Self-pay|Self-pay|785||||785|274.75|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|785||||785|232.75|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|785||||785|285.13|502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|785||||785||502.4|232.75
36020605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ INTERM JNT W/O US|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|785||||785||502.4|232.75
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|AARP [1000]|AARP [100000]|1022||||1022|119|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1022||||1022|239.2|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|AETNA [1015]|AETNA [101529]|1022||||1022|1022|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1022||||1022|303.02|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1022||||1022|236.83|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1022||||1022|236.83|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|BCBS [1155]|BCBS UTHCT [115568]|1022||||1022|1350|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1022||||1022|22.74|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1022||||1022|1682|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1022||||1022|1800|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1022||||1022|303.02|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1022||||1022|236.83|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|CIGNA [1260]|CIGNA GWH [126023]|1022||||1022|575|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1022||||1022|654.08|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1022||||1022|326.46|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1022||||1022|253.65|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1022||||1022|1022|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1022||||1022|303.02|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1022||||1022|236.83|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1022||||1022|1022|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1022||||1022|303.02|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1022||||1022|303.02|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1022||||1022|654.08|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1022||||1022|303.02|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|Self-pay|Self-pay|1022||||1022|357.7|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1022||||1022|303.02|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1022||||1022|285.13|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1022||||1022|119|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1022||||1022|236.83|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1022||||1022|236.83|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1022||||1022|119|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1022||||1022|236.83|1800|22.74
36020610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASP/INJ MAJOR JOINT W/O US|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1022||||1022|473.66|1800|22.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|AARP [1000]|AARP [100000]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|AETNA [1015]|AETNA [101529]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|704||||704|208.74|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|BCBS [1155]|BCBS UTHCT [115568]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|704||||704|208.74|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|CIGNA [1260]|CIGNA GWH [126023]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|GROUP PENSION ADMIN [1450]|GPA [145000]|704||||704|450.56|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|704||||704|326.46|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|704||||704|208.74|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|704||||704|208.74|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|704||||704|208.74|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|PHCS [1780]|PHCS MULTIPLAN [178000]|704||||704|450.56|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|704||||704|208.74|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|Self-pay|Self-pay|704||||704|246.4|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|704||||704|208.74|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|704||||704|285.13|450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|704||||704||450.56|208.74
36020611|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|704||||704||450.56|208.74
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|AARP [1000]|AARP [100000]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|AETNA [1015]|AETNA [101529]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|370||||370|109.71|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|BCBS [1155]|BCBS UTHCT [115568]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|370||||370|109.71|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|CIGNA [1260]|CIGNA GWH [126023]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|370||||370|236.8|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|370||||370|326.46|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|370||||370|109.71|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|370||||370|109.71|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|370||||370|109.71|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|370||||370|236.8|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|370||||370|109.71|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|Self-pay|Self-pay|370||||370|129.5|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|370||||370|109.71|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|370||||370|285.13|326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|370||||370||326.46|109.71
36020612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASPIRATION/INJ GANGLION CYST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|370||||370||326.46|109.71
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|AARP [1000]|AARP [100000]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|AETNA [1015]|AETNA [101529]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3048||||3048|903.73|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|BCBS [1155]|BCBS UTHCT [115568]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3048||||3048|903.73|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|CIGNA [1260]|CIGNA GWH [126023]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3048||||3048|1950.72|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3048||||3048|1758.75|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3048||||3048|903.73|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3048||||3048|903.73|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3048||||3048|903.73|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3048||||3048|1950.72|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3048||||3048|903.73|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|Self-pay|Self-pay|3048||||3048|1066.8|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3048||||3048|903.73|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3048||||3048|285.13|1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3048||||3048||1950.72|285.13
36020670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPLANT SUPERFICIAL SEP PROC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3048||||3048||1950.72|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AARP [1000]|AARP [100000]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AETNA [1015]|AETNA [101529]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7320||||7320|2170.38|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS [1155]|BCBS UTHCT [115568]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7320||||7320|2170.38|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|CIGNA [1260]|CIGNA GWH [126023]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7320||||7320|4684.8|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7320||||7320|1758.75|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7320||||7320|2170.38|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7320||||7320|2170.38|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|7320||||7320|2170.38|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7320||||7320|4684.8|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7320||||7320|2170.38|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|Self-pay|Self-pay|7320||||7320|2562|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7320||||7320|2170.38|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7320||||7320|285.13|4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7320||||7320||4684.8|285.13
36021550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISSUE NECK/THORAX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7320||||7320||4684.8|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|AARP [1000]|AARP [100000]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|AETNA [1015]|AETNA [101529]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2796||||2796|829.01|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|BCBS [1155]|BCBS UTHCT [115568]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2796||||2796|829.01|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|CIGNA [1260]|CIGNA GWH [126023]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2796||||2796|1789.44|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2796||||2796|2962.51|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2796||||2796|829.01|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2796||||2796|829.01|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2796||||2796|829.01|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2796||||2796|1789.44|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2796||||2796|829.01|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|Self-pay|Self-pay|2796||||2796|978.6|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2796||||2796|829.01|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2796||||2796|285.13|2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2796||||2796||2962.51|285.13
36023030|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D SHOULDER ABSCESS/HEMATOMA DEEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2796||||2796||2962.51|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|AARP [1000]|AARP [100000]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|AETNA [1015]|AETNA [101529]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1355||||1355|401.76|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1355||||1355|401.76|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1355||||1355|867.2|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1355||||1355|1740.44|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1355||||1355|401.76|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1355||||1355|401.76|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1355||||1355|401.76|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1355||||1355|867.2|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1355||||1355|401.76|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|Self-pay|Self-pay|1355||||1355|474.25|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1355||||1355|401.76|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1355||||1355|285.13|1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1355||||1355||1740.44|285.13
36023575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX SCAPULAR FX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1355||||1355||1740.44|285.13
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|AARP [1000]|AARP [100000]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|AETNA [1015]|AETNA [101529]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|611||||611|181.16|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|611||||611|181.16|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|611||||611|391.04|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|611||||611|257.74|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|611||||611|181.16|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|611||||611|181.16|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|611||||611|181.16|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|611||||611|391.04|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|611||||611|181.16|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|Self-pay|Self-pay|611||||611|213.85|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|611||||611|181.16|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|611||||611|285.13|391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|611||||611||391.04|181.16
36023650|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX SHOULDER DISLOCATION W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|611||||611||391.04|181.16
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|AARP [1000]|AARP [100000]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|AETNA [1015]|AETNA [101529]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3278||||3278|971.93|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3278||||3278|971.93|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3278||||3278|2097.92|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3278||||3278|1740.44|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3278||||3278|971.93|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3278||||3278|971.93|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3278||||3278|971.93|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3278||||3278|2097.92|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3278||||3278|971.93|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|Self-pay|Self-pay|3278||||3278|1147.3|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3278||||3278|971.93|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3278||||3278|285.13|2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3278||||3278||2097.92|285.13
36024505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX HUMERAL SHAFT W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3278||||3278||2097.92|285.13
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|AARP [1000]|AARP [100000]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|AETNA [1015]|AETNA [101529]|315||||315|315|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|315||||315|93.4|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|315||||315|93.4|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|315||||315|201.6|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|315||||315|257.74|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|315||||315|315|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|315||||315|93.4|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|315||||315|315|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|315||||315|93.4|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|315||||315|93.4|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|315||||315|201.6|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|315||||315|93.4|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|Self-pay|Self-pay|315||||315|110.25|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|315||||315|93.4|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|315||||315|285.13|315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|315||||315||315|93.4
36024640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX CHILD NURSEMAID ELBOW W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|315||||315||315|93.4
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|AARP [1000]|AARP [100000]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|AETNA [1015]|AETNA [101529]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1090||||1090|323.19|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1090||||1090|323.19|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1090||||1090|697.6|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1090||||1090|1740.44|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1090||||1090|323.19|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1090||||1090|323.19|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1090||||1090|323.19|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1090||||1090|697.6|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1090||||1090|323.19|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|Self-pay|Self-pay|1090||||1090|381.5|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1090||||1090|323.19|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1090||||1090|285.13|1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1090||||1090||1740.44|285.13
36024655|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX RADIAL HD/NCK FX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1090||||1090||1740.44|285.13
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|AARP [1000]|AARP [100000]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|AETNA [1015]|AETNA [101529]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|454||||454|134.61|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|454||||454|134.61|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|454||||454|290.56|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|454||||454|257.74|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|454||||454|134.61|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|454||||454|134.61|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|454||||454|134.61|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|454||||454|290.56|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|454||||454|134.61|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|Self-pay|Self-pay|454||||454|158.9|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|454||||454|134.61|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|454||||454|285.13|290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|454||||454||290.56|134.61
36024670|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX ULNAR FRACTURE W/O MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|454||||454||290.56|134.61
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|AARP [1000]|AARP [100000]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|AETNA [1015]|AETNA [101529]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1136||||1136|336.82|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1136||||1136|336.82|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1136||||1136|727.04|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1136||||1136|1740.44|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1136||||1136|336.82|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1136||||1136|336.82|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1136||||1136|336.82|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1136||||1136|727.04|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1136||||1136|336.82|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|Self-pay|Self-pay|1136||||1136|397.6|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1136||||1136|336.82|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1136||||1136|381.79|1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1136||||1136||1740.44|336.82
36025565|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX RADIUS & ULNAR SHAFT FX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1136||||1136||1740.44|336.82
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|AARP [1000]|AARP [100000]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|AETNA [1015]|AETNA [101529]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|260||||260|77.09|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|260||||260|77.09|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|260||||260|166.4|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|260||||260|257.74|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|260||||260|77.09|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|260||||260|77.09|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|260||||260|77.09|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|260||||260|166.4|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|260||||260|77.09|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|Self-pay|Self-pay|260||||260|91|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|260||||260|77.09|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|260||||260|260|260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|260||||260||260|77.09
36025600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/O MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|260||||260||260|77.09
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|AARP [1000]|AARP [100000]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|AETNA [1015]|AETNA [101529]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|858||||858|254.4|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|858||||858|254.4|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|858||||858|549.12|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|858||||858|1740.44|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|858||||858|254.4|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|858||||858|254.4|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|858||||858|254.4|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|858||||858|549.12|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|858||||858|254.4|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|Self-pay|Self-pay|858||||858|300.3|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|858||||858|254.4|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|858||||858|437.85|1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|858||||858||1740.44|254.4
36025605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX RADIUS/ULNA W/MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|858||||858||1740.44|254.4
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|AARP [1000]|AARP [100000]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|AETNA [1015]|AETNA [101529]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|561||||561|166.34|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|561||||561|166.34|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|561||||561|359.04|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|561||||561|257.74|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|561||||561|166.34|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|561||||561|166.34|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|561||||561|166.34|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|561||||561|359.04|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|561||||561|166.34|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|Self-pay|Self-pay|561||||561|196.35|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|561||||561|166.34|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|561||||561|285.13|359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|561||||561||359.04|166.34
36025675|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLSD TX DISLOCATION RADIOULNAR W/MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|561||||561||359.04|166.34
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|AARP [1000]|AARP [100000]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|AETNA [1015]|AETNA [101529]|440||||440|440|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|440||||440|130.46|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|BCBS [1155]|BCBS UTHCT [115568]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|440||||440|130.46|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|CIGNA [1260]|CIGNA GWH [126023]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|440||||440|281.6|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|440||||440|224.44|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|440||||440|440|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|440||||440|130.46|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|440||||440|440|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|440||||440|130.46|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|440||||440|130.46|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|440||||440|281.6|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|440||||440|130.46|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|Self-pay|Self-pay|440||||440|154|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|440||||440|130.46|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|440||||440|285.13|440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|440||||440||440|130.46
36026010|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE FINGER ABSCESS SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|440||||440||440|130.46
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|AARP [1000]|AARP [100000]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|AETNA [1015]|AETNA [101529]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3692||||3692|1094.68|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|BCBS [1155]|BCBS UTHCT [115568]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3692||||3692|1094.68|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|CIGNA [1260]|CIGNA GWH [126023]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3692||||3692|2362.88|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3692||||3692|1758.75|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3692||||3692|1094.68|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3692||||3692|1094.68|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3692||||3692|1094.68|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3692||||3692|2362.88|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3692||||3692|1094.68|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|Self-pay|Self-pay|3692||||3692|1292.2|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3692||||3692|1094.68|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3692||||3692|381.79|2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3692||||3692||2362.88|381.79
36026115|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3692||||3692||2362.88|381.79
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|AARP [1000]|AARP [100000]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|AETNA [1015]|AETNA [101529]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|410||||410|121.57|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|BCBS [1155]|BCBS UTHCT [115568]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|410||||410|121.57|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|CIGNA [1260]|CIGNA GWH [126023]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|410||||410|262.4|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|410||||410|257.74|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|410||||410|121.57|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|410||||410|121.57|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|410||||410|121.57|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|410||||410|262.4|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|410||||410|121.57|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|Self-pay|Self-pay|410||||410|143.5|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|410||||410|121.57|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|410||||410|381.79|381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|410||||410||381.79|121.57
36026605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX METACARPAL FX W/ MANIP EACH BONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|410||||410||381.79|121.57
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|AARP [1000]|AARP [100000]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|AETNA [1015]|AETNA [101529]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3523||||3523|1044.57|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|BCBS [1155]|BCBS UTHCT [115568]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3523||||3523|1044.57|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|CIGNA [1260]|CIGNA GWH [126023]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3523||||3523|2254.72|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3523||||3523|1740.44|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3523||||3523|1044.57|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3523||||3523|1044.57|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3523||||3523|1044.57|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3523||||3523|2254.72|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3523||||3523|1044.57|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|Self-pay|Self-pay|3523||||3523|1233.05|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3523||||3523|1044.57|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3523||||3523|285.13|2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3523||||3523||2254.72|285.13
36026645|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLTX CARPO/METACARPAL FX DISLC THUMB W/MANJ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3523||||3523||2254.72|285.13
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|AARP [1000]|AARP [100000]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|AETNA [1015]|AETNA [101529]|351||||351|351|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|351||||351|104.07|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|BCBS [1155]|BCBS UTHCT [115568]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|351||||351|104.07|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|CIGNA [1260]|CIGNA GWH [126023]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|351||||351|224.64|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|351||||351|257.74|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|351||||351|351|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|351||||351|104.07|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|351||||351|351|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|351||||351|104.07|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|351||||351|104.07|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|351||||351|224.64|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|351||||351|104.07|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|Self-pay|Self-pay|351||||351|122.85|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|351||||351|104.07|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|351||||351|285.13|351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|351||||351||351|104.07
36026700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX M-P DISLOC W/O ANES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|351||||351||351|104.07
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|AARP [1000]|AARP [100000]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|AETNA [1015]|AETNA [101529]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|387||||387|114.75|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|387||||387|114.75|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|387||||387|247.68|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|387||||387|257.74|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|387||||387|114.75|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|387||||387|114.75|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|387||||387|114.75|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|387||||387|247.68|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|387||||387|114.75|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|Self-pay|Self-pay|387||||387|135.45|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|387||||387|114.75|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|387||||387|285.13|285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|387||||387||285.13|114.75
36026725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX PROX/MIDDLE PHALANX FX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|387||||387||285.13|114.75
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|AARP [1000]|AARP [100000]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|AETNA [1015]|AETNA [101529]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|535||||535|158.63|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|535||||535|158.63|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|535||||535|342.4|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|535||||535|1740.44|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|535||||535|158.63|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|535||||535|158.63|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|535||||535|158.63|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|535||||535|342.4|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|535||||535|158.63|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|Self-pay|Self-pay|535||||535|187.25|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|535||||535|158.63|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|535||||535|381.79|1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|535||||535||1740.44|158.63
36026742|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX ARTCLR FX METACARP/INTERPHAL JT W/MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|535||||535||1740.44|158.63
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|AARP [1000]|AARP [100000]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|AETNA [1015]|AETNA [101529]|308||||308|308|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|308||||308|91.32|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|308||||308|91.32|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|308||||308|197.12|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|308||||308|257.74|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|308||||308|308|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|308||||308|91.32|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|308||||308|308|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|308||||308|91.32|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|308||||308|91.32|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|308||||308|197.12|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|308||||308|91.32|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|Self-pay|Self-pay|308||||308|107.8|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|308||||308|91.32|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|308||||308|285.13|308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|308||||308||308|91.32
36026755|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX DISTAL PHALANX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|308||||308||308|91.32
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|AARP [1000]|AARP [100000]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|AETNA [1015]|AETNA [101529]|387||||387|387|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|387||||387|114.75|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|BCBS [1155]|BCBS UTHCT [115568]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|387||||387|114.75|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|CIGNA [1260]|CIGNA GWH [126023]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|387||||387|247.68|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|387||||387|257.74|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|387||||387|387|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|387||||387|114.75|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|387||||387|387|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|387||||387|114.75|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|387||||387|114.75|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|387||||387|247.68|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|387||||387|114.75|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|Self-pay|Self-pay|387||||387|135.45|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|387||||387|114.75|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|387||||387|285.13|387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|387||||387||387|114.75
36026770|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX I-P JOINT DISLOC W/MANIP W/O ANES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|387||||387||387|114.75
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|AARP [1000]|AARP [100000]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|AETNA [1015]|AETNA [101529]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3237||||3237|959.77|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|BCBS [1155]|BCBS UTHCT [115568]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3237||||3237|959.77|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|CIGNA [1260]|CIGNA GWH [126023]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3237||||3237|2071.68|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3237||||3237|1758.75|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3237||||3237|959.77|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3237||||3237|959.77|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3237||||3237|959.77|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3237||||3237|2071.68|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3237||||3237|959.77|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|Self-pay|Self-pay|3237||||3237|1132.95|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3237||||3237|959.77|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3237||||3237|381.79|2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3237||||3237||2071.68|381.79
36027041|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY SOFT TISS/PELV/HIP DEEP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3237||||3237||2071.68|381.79
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|AARP [1000]|AARP [100000]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|AETNA [1015]|AETNA [101529]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|925||||925|274.26|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|BCBS [1155]|BCBS UTHCT [115568]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|925||||925|0|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|925||||925|274.26|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|CIGNA [1260]|CIGNA GWH [126023]|925||||925|0|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|925||||925|592|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|925||||925|462.5|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|925||||925|274.26|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|925||||925|274.26|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|925||||925|274.26|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|925||||925|592|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|925||||925|274.26|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|Self-pay|Self-pay|925||||925|323.75|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|925||||925|274.26|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|925||||925|274.26|592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|925||||925||592|274.26
36027369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|925||||925||592|274.26
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|AARP [1000]|AARP [100000]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|AETNA [1015]|AETNA [101529]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3663||||3663|1086.08|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3663||||3663|1086.08|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3663||||3663|2344.32|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3663||||3663|1740.44|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3663||||3663|1086.08|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3663||||3663|1086.08|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3663||||3663|1086.08|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3663||||3663|2344.32|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3663||||3663|1086.08|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|Self-pay|Self-pay|3663||||3663|1282.05|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3663||||3663|1086.08|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3663||||3663|285.13|2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3663||||3663||2344.32|285.13
36027752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TIB SHFT FX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3663||||3663||2344.32|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|AARP [1000]|AARP [100000]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|AETNA [1015]|AETNA [101529]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2939||||2939|871.41|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2939||||2939|871.41|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2939||||2939|1880.96|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2939||||2939|1740.44|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2939||||2939|871.41|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2939||||2939|871.41|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2939||||2939|871.41|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2939||||2939|1880.96|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2939||||2939|871.41|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|Self-pay|Self-pay|2939||||2939|1028.65|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2939||||2939|871.41|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2939||||2939|285.13|1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2939||||2939||1880.96|285.13
36027762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLS TX MD MALLEOL ANKL FX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2939||||2939||1880.96|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|AARP [1000]|AARP [100000]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|AETNA [1015]|AETNA [101529]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2710||||2710|803.52|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2710||||2710|803.52|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2710||||2710|1734.4|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2710||||2710|1740.44|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2710||||2710|803.52|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2710||||2710|803.52|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2710||||2710|803.52|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2710||||2710|1734.4|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2710||||2710|803.52|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|Self-pay|Self-pay|2710||||2710|948.5|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2710||||2710|803.52|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2710||||2710|285.13|1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2710||||2710||1740.44|285.13
36027818|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TRIMALL ANKLE FX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2710||||2710||1740.44|285.13
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|AARP [1000]|AARP [100000]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|AETNA [1015]|AETNA [101529]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|508||||508|150.62|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|BCBS [1155]|BCBS UTHCT [115568]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|508||||508|150.62|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|CIGNA [1260]|CIGNA GWH [126023]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|508||||508|325.12|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|508||||508|257.74|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|508||||508|150.62|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|508||||508|150.62|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|508||||508|150.62|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|508||||508|325.12|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|508||||508|150.62|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|Self-pay|Self-pay|508||||508|177.8|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|508||||508|150.62|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|508||||508|285.13|325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|508||||508||325.12|150.62
36027840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSD TX ANKLE DISLOC W/O ANES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|508||||508||325.12|150.62
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|AARP [1000]|AARP [100000]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|AETNA [1015]|AETNA [101529]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2584||||2584|766.16|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|BCBS [1155]|BCBS UTHCT [115568]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2584||||2584|766.16|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|CIGNA [1260]|CIGNA GWH [126023]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2584||||2584|1653.76|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2584||||2584|777.46|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2584||||2584|766.16|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2584||||2584|766.16|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2584||||2584|766.16|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2584||||2584|1653.76|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2584||||2584|766.16|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|Self-pay|Self-pay|2584||||2584|904.4|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2584||||2584|766.16|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2584||||2584|285.13|1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2584||||2584||1653.76|285.13
36028190|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE FB FOOT SUBQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2584||||2584||1653.76|285.13
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|AARP [1000]|AARP [100000]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|AETNA [1015]|AETNA [101529]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3525||||3525|1045.16|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3525||||3525|1045.16|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3525||||3525|2256|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3525||||3525|1740.44|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3525||||3525|1045.16|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3525||||3525|1045.16|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3525||||3525|1045.16|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3525||||3525|2256|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3525||||3525|1045.16|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|Self-pay|Self-pay|3525||||3525|1233.75|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3525||||3525|1045.16|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3525||||3525|381.79|2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3525||||3525||2256|381.79
36028435|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX TALUS FX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3525||||3525||2256|381.79
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|AARP [1000]|AARP [100000]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|AETNA [1015]|AETNA [101529]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|365||||365|108.22|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|365||||365|108.22|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|365||||365|233.6|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|365||||365|257.74|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|365||||365|108.22|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|365||||365|108.22|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|365||||365|108.22|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|365||||365|233.6|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|365||||365|108.22|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|Self-pay|Self-pay|365||||365|127.75|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|365||||365|108.22|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|365||||365|285.13|285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|365||||365||285.13|108.22
36028495|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FX GREAT TOE W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|365||||365||285.13|108.22
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|AARP [1000]|AARP [100000]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|AETNA [1015]|AETNA [101529]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|385||||385|114.15|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|BCBS [1155]|BCBS UTHCT [115568]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|385||||385|114.15|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|CIGNA [1260]|CIGNA GWH [126023]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|385||||385|246.4|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|385||||385|257.74|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|385||||385|114.15|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|385||||385|114.15|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|385||||385|114.15|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|385||||385|246.4|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|385||||385|114.15|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|Self-pay|Self-pay|385||||385|134.75|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|385||||385|114.15|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|385||||385|285.13|285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|385||||385||285.13|114.15
36028515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CLOSED TX FRACTURE PHALANX W/ MANIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|385||||385||285.13|114.15
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|AARP [1000]|AARP [100000]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|AETNA [1015]|AETNA [101529]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|538||||538|159.52|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|BCBS [1155]|BCBS UTHCT [115568]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|538||||538|159.52|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|CIGNA [1260]|CIGNA GWH [126023]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|538||||538|344.32|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|538||||538|257.74|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|538||||538|159.52|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|538||||538|159.52|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|538||||538|159.52|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|538||||538|344.32|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|538||||538|159.52|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|Self-pay|Self-pay|538||||538|188.3|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|538||||538|159.52|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|538||||538|285.13|344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|538||||538||344.32|159.52
36028630|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX METATAR-PHALANG JNT DISL W/O ANES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|538||||538||344.32|159.52
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|AARP [1000]|AARP [100000]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|AETNA [1015]|AETNA [101529]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|354||||354|104.96|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|BCBS [1155]|BCBS UTHCT [115568]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|354||||354|104.96|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|CIGNA [1260]|CIGNA GWH [126023]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|354||||354|226.56|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|354||||354|257.74|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|354||||354|104.96|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|354||||354|104.96|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|354||||354|104.96|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|354||||354|226.56|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|354||||354|104.96|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|Self-pay|Self-pay|354||||354|123.9|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|354||||354|104.96|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|354||||354|285.13|285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|354||||354||285.13|104.96
36028660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CL TX INTERPHLNG JNT DISLC W/O ANES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|354||||354||285.13|104.96
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|AARP [1000]|AARP [100000]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|AETNA [1015]|AETNA [101529]|632||||632|632|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|632||||632|187.39|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|BCBS [1155]|BCBS UTHCT [115568]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|632||||632|187.39|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|CIGNA [1260]|CIGNA GWH [126023]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|632||||632|404.48|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|632||||632|301.46|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|632||||632|632|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|632||||632|187.39|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|632||||632|632|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|632||||632|187.39|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|632||||632|187.39|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|632||||632|404.48|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|632||||632|187.39|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|Self-pay|Self-pay|632||||632|221.2|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|632||||632|187.39|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|632||||632|381.79|632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|632||||632||632|187.39
36029075|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY CAST SHORT ARM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|632||||632||632|187.39
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|AARP [1000]|AARP [100000]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|AETNA [1015]|AETNA [101529]|375||||375|375|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|375||||375|111.19|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|BCBS [1155]|BCBS UTHCT [115568]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|375||||375|111.19|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|CIGNA [1260]|CIGNA GWH [126023]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|375||||375|240|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|375||||375|176.48|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|375||||375|375|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|375||||375|111.19|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|375||||375|375|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|375||||375|111.19|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|375||||375|111.19|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|375||||375|240|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|375||||375|111.19|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|Self-pay|Self-pay|375||||375|131.25|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|375||||375|111.19|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|375||||375|285.13|375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|375||||375||375|111.19
36029105|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG ARM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|375||||375||375|111.19
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AARP [1000]|AARP [100000]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AETNA [1015]|AETNA [101529]|345||||345|345|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|345||||345|102.29|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS [1155]|BCBS UTHCT [115568]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|345||||345|102.29|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|CIGNA [1260]|CIGNA GWH [126023]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|345||||345|220.8|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|345||||345|139.94|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|345||||345|345|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|345||||345|102.29|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|345||||345|345|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|345||||345|102.29|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|345||||345|102.29|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|345||||345|220.8|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|345||||345|102.29|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|Self-pay|Self-pay|345||||345|120.75|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|345||||345|102.29|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|345||||345|102.29|345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|345||||345||345|102.29
36029125|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT ARM STATIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|345||||345||345|102.29
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|AARP [1000]|AARP [100000]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|AETNA [1015]|AETNA [101529]|215||||215|215|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|215||||215|63.75|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|BCBS [1155]|BCBS UTHCT [115568]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|215||||215|63.75|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|CIGNA [1260]|CIGNA GWH [126023]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|215||||215|137.6|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|215||||215|139.94|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|215||||215|215|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|215||||215|63.75|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|215||||215|215|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|215||||215|63.75|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|215||||215|63.75|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|215||||215|137.6|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|215||||215|63.75|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|Self-pay|Self-pay|215||||215|75.25|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|215||||215|63.75|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|215||||215|63.75|215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|215||||215||215|63.75
36029130|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT FINGER STATIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|215||||215||215|63.75
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|AARP [1000]|AARP [100000]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|AETNA [1015]|AETNA [101529]|217||||217|217|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217||||217|64.34|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS [1155]|BCBS UTHCT [115568]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217||||217|64.34|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|CIGNA [1260]|CIGNA GWH [126023]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|217||||217|138.88|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|217||||217|69.58|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217||||217|217|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217||||217|64.34|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217||||217|217|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217||||217|64.34|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|217||||217|64.34|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|217||||217|138.88|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217||||217|64.34|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|Self-pay|Self-pay|217||||217|75.95|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|217||||217|64.34|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217||||217|64.34|217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217||||217||217|64.34
36029280|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING HAND/FINGER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217||||217||217|64.34
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|AARP [1000]|AARP [100000]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|AETNA [1015]|AETNA [101529]|482||||482|482|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|482||||482|142.91|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|BCBS [1155]|BCBS UTHCT [115568]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|482||||482|142.91|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|CIGNA [1260]|CIGNA GWH [126023]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|482||||482|308.48|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|482||||482|301.46|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|482||||482|482|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|482||||482|142.91|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|482||||482|482|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|482||||482|142.91|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|482||||482|142.91|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|482||||482|308.48|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|482||||482|142.91|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|Self-pay|Self-pay|482||||482|168.7|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|482||||482|142.91|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|482||||482|381.79|482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|482||||482||482|142.91
36029405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLICATION SHORT LEG CAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|482||||482||482|142.91
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|AARP [1000]|AARP [100000]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|AETNA [1015]|AETNA [101529]|345||||345|345|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|345||||345|102.29|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|BCBS [1155]|BCBS UTHCT [115568]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|345||||345|102.29|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|CIGNA [1260]|CIGNA GWH [126023]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|345||||345|220.8|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|345||||345|301.46|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|345||||345|345|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|345||||345|102.29|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|345||||345|345|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|345||||345|102.29|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|345||||345|102.29|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|345||||345|220.8|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|345||||345|102.29|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|Self-pay|Self-pay|345||||345|120.75|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|345||||345|102.29|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|345||||345|345|345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|345||||345||345|102.29
36029445|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPL CAST LEG RIGID TOTAL CONT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|345||||345||345|102.29
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|AARP [1000]|AARP [100000]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|AETNA [1015]|AETNA [101529]|337||||337|337|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|337||||337|99.92|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|BCBS [1155]|BCBS UTHCT [115568]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|337||||337|99.92|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|CIGNA [1260]|CIGNA GWH [126023]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|337||||337|215.68|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|337||||337|176.48|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|337||||337|337|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|337||||337|99.92|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|337||||337|337|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|337||||337|99.92|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|337||||337|99.92|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|337||||337|215.68|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|337||||337|99.92|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|Self-pay|Self-pay|337||||337|117.95|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|337||||337|99.92|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|337||||337|285.13|337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|337||||337||337|99.92
36029505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT LONG LEG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|AARP [1000]|AARP [100000]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|AETNA [1015]|AETNA [101529]|337||||337|337|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|337||||337|99.92|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|BCBS [1155]|BCBS UTHCT [115568]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|337||||337|99.92|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|CIGNA [1260]|CIGNA GWH [126023]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|337||||337|215.68|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|337||||337|176.48|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|337||||337|337|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|337||||337|99.92|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|337||||337|337|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|337||||337|99.92|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|337||||337|99.92|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|337||||337|215.68|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|337||||337|99.92|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|Self-pay|Self-pay|337||||337|117.95|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|337||||337|99.92|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|337||||337|285.13|337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|337||||337||337|99.92
36029515|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APPLY SPLINT SHORT LEG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|337||||337||337|99.92
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|AARP [1000]|AARP [100000]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|AETNA [1015]|AETNA [101529]|235||||235|235|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|235||||235|69.68|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|BCBS [1155]|BCBS UTHCT [115568]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|235||||235|69.68|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|CIGNA [1260]|CIGNA GWH [126023]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|235||||235|150.4|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|235||||235|139.94|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|235||||235|235|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|235||||235|69.68|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|235||||235|235|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|235||||235|69.68|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|235||||235|69.68|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|235||||235|150.4|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|235||||235|69.68|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|Self-pay|Self-pay|235||||235|82.25|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|235||||235|69.68|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|235||||235|69.68|235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|235||||235||235|69.68
36029530|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING KNEE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|235||||235||235|69.68
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|AARP [1000]|AARP [100000]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|AETNA [1015]|AETNA [101529]|386||||386|386|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386||||386|114.45|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS [1155]|BCBS UTHCT [115568]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386||||386|114.45|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|CIGNA [1260]|CIGNA GWH [126023]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386||||386|247.04|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|386||||386|176.48|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386||||386|386|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386||||386|114.45|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386||||386|386|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386||||386|114.45|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|386||||386|114.45|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386||||386|247.04|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386||||386|114.45|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|Self-pay|Self-pay|386||||386|135.1|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|386||||386|114.45|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386||||386|285.13|386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386||||386||386|114.45
36029540|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING ANKLE/FOOT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386||||386||386|114.45
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|AARP [1000]|AARP [100000]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|AETNA [1015]|AETNA [101529]|244||||244|244|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244||||244|72.35|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|BCBS [1155]|BCBS UTHCT [115568]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244||||244|72.35|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|CIGNA [1260]|CIGNA GWH [126023]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|244||||244|156.16|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|244||||244|69.58|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244||||244|244|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244||||244|72.35|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244||||244|244|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244||||244|72.35|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|244||||244|72.35|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|244||||244|156.16|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244||||244|72.35|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|Self-pay|Self-pay|244||||244|85.4|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|244||||244|72.35|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244||||244|72.35|244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244||||244||244|69.58
36029550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC STRAPPING TOES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244||||244||244|69.58
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|AARP [1000]|AARP [100000]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|AETNA [1015]|AETNA [101529]|258||||258|258|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|258||||258|76.5|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|BCBS [1155]|BCBS UTHCT [115568]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|258||||258|76.5|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|CIGNA [1260]|CIGNA GWH [126023]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|258||||258|165.12|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|258||||258|176.48|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|258||||258|258|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|258||||258|76.5|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|258||||258|258|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|258||||258|76.5|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|258||||258|76.5|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|258||||258|165.12|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|258||||258|76.5|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|Self-pay|Self-pay|258||||258|90.3|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|258||||258|76.5|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|258||||258|258|258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|258||||258||258|76.5
36029580|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNNA BOOT APPLICATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|258||||258||258|76.5
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AARP [1000]|AARP [100000]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AETNA [1015]|AETNA [101529]|694||||694|694|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|694||||694|205.77|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS [1155]|BCBS UTHCT [115568]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|694||||694|205.77|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|CIGNA [1260]|CIGNA GWH [126023]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|694||||694|444.16|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|694||||694|176.48|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|694||||694|694|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|694||||694|205.77|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|694||||694|694|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|694||||694|205.77|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|694||||694|205.77|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|694||||694|444.16|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|694||||694|205.77|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|Self-pay|Self-pay|694||||694|242.9|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|694||||694|205.77|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|694||||694|41.3|694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|694||||694||694|41.3
36029581|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|694||||694||694|41.3
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|AARP [1000]|AARP [100000]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|AETNA [1015]|AETNA [101529]|336||||336|336|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|336||||336|99.62|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|BCBS [1155]|BCBS UTHCT [115568]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|336||||336|99.62|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|CIGNA [1260]|CIGNA GWH [126023]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|336||||336|215.04|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|336||||336|176.48|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|336||||336|336|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|336||||336|99.62|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|336||||336|336|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|336||||336|99.62|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|336||||336|99.62|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|336||||336|215.04|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|336||||336|99.62|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|Self-pay|Self-pay|336||||336|117.6|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|336||||336|99.62|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|336||||336|285.13|336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|336||||336||336|99.62
36029799|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UNLISTED PROC CASTINGS/STRAPPI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|336||||336||336|99.62
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|AARP [1000]|AARP [100000]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|AETNA [1015]|AETNA [101529]|396||||396|396|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|396||||396|117.41|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|BCBS [1155]|BCBS UTHCT [115568]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|396||||396|117.41|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|CIGNA [1260]|CIGNA GWH [126023]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|396||||396|253.44|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|396||||396|139.94|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|396||||396|396|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|396||||396|117.41|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|396||||396|396|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|396||||396|117.41|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|396||||396|117.41|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|396||||396|253.44|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|396||||396|117.41|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|Self-pay|Self-pay|396||||396|138.6|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|396||||396|117.41|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|396||||396|117.41|396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|396||||396||396|117.41
36030300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE NASAL FB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|396||||396||396|117.41
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|AARP [1000]|AARP [100000]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|AETNA [1015]|AETNA [101529]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|432||||432|128.09|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|BCBS [1155]|BCBS UTHCT [115568]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|432||||432|128.09|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|CIGNA [1260]|CIGNA GWH [126023]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|432||||432|276.48|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|432||||432|139.94|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|432||||432|128.09|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|432||||432|128.09|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|432||||432|128.09|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|432||||432|276.48|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|432||||432|128.09|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|Self-pay|Self-pay|432||||432|151.2|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|432||||432|128.09|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|432||||432|128.09|276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|432||||432||276.48|128.09
36030901|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CONTROL NOSEBLEED ANTER SIMPL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|432||||432||276.48|128.09
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|AARP [1000]|AARP [100000]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|AETNA [1015]|AETNA [101529]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|317||||317|93.99|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|BCBS [1155]|BCBS UTHCT [115568]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|317||||317|93.99|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|CIGNA [1260]|CIGNA GWH [126023]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|317||||317|202.88|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|317||||317|139.94|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|317||||317|93.99|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|317||||317|93.99|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|317||||317|93.99|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|317||||317|202.88|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|317||||317|93.99|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|Self-pay|Self-pay|317||||317|110.95|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|317||||317|93.99|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|317||||317|285.13|285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|317||||317||285.13|93.99
36030903|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CNTRL NOSEBLEED ANTERIOR CMPLX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|317||||317||285.13|93.99
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AARP [1000]|AARP [100000]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AETNA [1015]|AETNA [101529]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|769||||769|228.01|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS [1155]|BCBS UTHCT [115568]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|769||||769|228.01|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|CIGNA [1260]|CIGNA GWH [126023]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|769||||769|492.16|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|769||||769|264.5|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|769||||769|228.01|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|769||||769|228.01|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|769||||769|228.01|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|769||||769|492.16|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|769||||769|228.01|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|Self-pay|Self-pay|769||||769|269.15|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|769||||769|228.01|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|769||||769|285.13|492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|769||||769||492.16|228.01
36031500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTUBATION ENDOTRACHEAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|769||||769||492.16|228.01
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|AARP [1000]|AARP [100000]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|AETNA [1015]|AETNA [101529]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|598||||598|177.31|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|BCBS [1155]|BCBS UTHCT [115568]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|598||||598|177.31|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|CIGNA [1260]|CIGNA GWH [126023]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|598||||598|382.72|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|598||||598|205.49|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|598||||598|177.31|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|598||||598|177.31|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|598||||598|177.31|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|598||||598|382.72|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|598||||598|177.31|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|Self-pay|Self-pay|598||||598|209.3|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|598||||598|177.31|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|598||||598|285.13|382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|598||||598||382.72|177.31
36031575|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LARYNGOSCOPY FLEX FIBEROPTIC DX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|598||||598||382.72|177.31
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AARP [1000]|AARP [100000]|3419||||3419|567|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3419||||3419|1370.53|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AETNA [1015]|AETNA [101529]|3419||||3419|2200|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3419||||3419|1013.73|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3419||||3419|1356.96|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3419||||3419|1356.96|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS [1155]|BCBS UTHCT [115568]|3419||||3419|667|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3419||||3419|1032.48|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3419||||3419|889|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3419||||3419|889|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3419||||3419|1013.73|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3419||||3419|1356.96|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|CIGNA [1260]|CIGNA GWH [126023]|3419||||3419|575|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3419||||3419|2188.16|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3419||||3419|1870.49|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3419||||3419|1453.3|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3419||||3419|2200|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3419||||3419|1013.73|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3419||||3419|1356.96|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3419||||3419|2200|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3419||||3419|1013.73|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3419||||3419|1013.73|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3419||||3419|2188.16|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3419||||3419|1013.73|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|Self-pay|Self-pay|3419||||3419|1196.65|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3419||||3419|1013.73|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3419||||3419|285.13|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3419||||3419|567|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3419||||3419|1356.96|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3419||||3419|1356.96|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3419||||3419|567|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3419||||3419|1356.96|2713.91|285.13
36031622|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3419||||3419|2713.91|2713.91|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AARP [1000]|AARP [100000]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AETNA [1015]|AETNA [101529]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3462.9||||3462.9|1026.75|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS [1155]|BCBS UTHCT [115568]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3462.9||||3462.9|1026.75|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|CIGNA [1260]|CIGNA GWH [126023]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3462.9||||3462.9|2216.26|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3462.9||||3462.9|1870.49|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3462.9||||3462.9|1026.75|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3462.9||||3462.9|1026.75|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3462.9||||3462.9|1026.75|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3462.9||||3462.9|2216.26|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3462.9||||3462.9|1026.75|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|Self-pay|Self-pay|3462.9||||3462.9|1212.01|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3462.9||||3462.9|1026.75|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3462.9||||3462.9|285.13|2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3462.9||||3462.9||2216.26|285.13
36031623|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSCOPY W/BRUSHING(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3462.9||||3462.9||2216.26|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AARP [1000]|AARP [100000]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AETNA [1015]|AETNA [101529]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3463.59||||3463.59|1026.95|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BCBS UTHCT [115568]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3463.59||||3463.59|1026.95|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|CIGNA [1260]|CIGNA GWH [126023]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3463.59||||3463.59|2216.7|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3463.59||||3463.59|1870.49|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3463.59||||3463.59|1026.95|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3463.59||||3463.59|1026.95|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3463.59||||3463.59|1026.95|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3463.59||||3463.59|2216.7|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3463.59||||3463.59|1026.95|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|Self-pay|Self-pay|3463.59||||3463.59|1212.26|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3463.59||||3463.59|1026.95|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3463.59||||3463.59|285.13|2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3463.59||||3463.59||2216.7|285.13
36031624|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BRONCHOSC ALVEOLAR LAVAGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3463.59||||3463.59||2216.7|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|AARP [1000]|AARP [100000]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|AETNA [1015]|AETNA [101529]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1379||||1379|408.87|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|BCBS [1155]|BCBS UTHCT [115568]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1379||||1379|408.87|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|CIGNA [1260]|CIGNA GWH [126023]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1379||||1379|882.56|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1379||||1379|1758.75|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1379||||1379|408.87|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1379||||1379|408.87|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1379||||1379|408.87|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1379||||1379|882.56|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1379||||1379|408.87|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|Self-pay|Self-pay|1379||||1379|482.65|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1379||||1379|408.87|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1379||||1379|285.13|1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1379||||1379||1758.75|285.13
36032400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BX PLEURA PERC NDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1379||||1379||1758.75|285.13
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|AARP [1000]|AARP [100000]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|AETNA [1015]|AETNA [101529]|3828||||3828|3500|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3828||||3828|1135|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|BCBS [1155]|BCBS UTHCT [115568]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3828||||3828|1135|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|CIGNA [1260]|CIGNA GWH [126023]|3828||||3828|0|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3828||||3828|2449.92|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3828||||3828|1758.75|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3828||||3828|3500|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3828||||3828|1135|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3828||||3828|3500|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3828||||3828|1135|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3828||||3828|1135|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3828||||3828|2449.92|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3828||||3828|1135|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|Self-pay|Self-pay|3828||||3828|1339.8|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3828||||3828|1135|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3828||||3828|1135|3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3828||||3828||3500|1135
36032408|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3828||||3828||3500|1135
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|AARP [1000]|AARP [100000]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|AETNA [1015]|AETNA [101529]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6675||||6675|1979.14|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|BCBS [1155]|BCBS UTHCT [115568]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6675||||6675|1979.14|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|CIGNA [1260]|CIGNA GWH [126023]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6675||||6675|4272|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6675||||6675|3979.26|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6675||||6675|1979.14|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6675||||6675|1979.14|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6675||||6675|1979.14|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6675||||6675|4272|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6675||||6675|1979.14|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|Self-pay|Self-pay|6675||||6675|2336.25|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6675||||6675|1979.14|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6675||||6675|1111.54|4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6675||||6675||4272|1111.54
36032550|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELL TUNNELLED PLEURAL CATH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6675||||6675||4272|1111.54
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|AARP [1000]|AARP [100000]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|AETNA [1015]|AETNA [101529]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|958||||958|284.05|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|BCBS [1155]|BCBS UTHCT [115568]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|958||||958|284.05|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|CIGNA [1260]|CIGNA GWH [126023]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|958||||958|613.12|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|958||||958|1757.68|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|958||||958|284.05|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|958||||958|284.05|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|958||||958|284.05|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|958||||958|613.12|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|958||||958|284.05|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|Self-pay|Self-pay|958||||958|335.3|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|958||||958|284.05|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|958||||958|284.05|1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|958||||958||1757.68|284.05
36032551|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERTION OF CHEST TUBE OPEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|958||||958||1757.68|284.05
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|AARP [1000]|AARP [100000]|1704||||1704|361|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1704||||1704|496.06|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|AETNA [1015]|AETNA [101529]|1704||||1704|1704|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1704||||1704|505.24|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1704||||1704|491.15|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1704||||1704|491.15|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|1704||||1704|1350|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1704||||1704|477.8|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1704||||1704|1682|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1704||||1704|1800|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1704||||1704|505.24|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1704||||1704|491.15|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|1704||||1704|575|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1704||||1704|1090.56|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1704||||1704|677.03|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1704||||1704|526.02|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1704||||1704|1704|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1704||||1704|505.24|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1704||||1704|491.15|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1704||||1704|1704|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1704||||1704|505.24|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1704||||1704|505.24|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1704||||1704|1090.56|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1704||||1704|505.24|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|Self-pay|Self-pay|1704||||1704|596.4|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1704||||1704|505.24|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1704||||1704|181.11|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1704||||1704|361|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1704||||1704|491.15|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1704||||1704|491.15|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1704||||1704|361|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1704||||1704|491.15|1800|181.11
36032554|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/O IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1704||||1704|982.3|1800|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|AARP [1000]|AARP [100000]|1842||||1842|361|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1842||||1842|496.06|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|AETNA [1015]|AETNA [101529]|1842||||1842|1842|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1842||||1842|546.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1842||||1842|491.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1842||||1842|491.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|1842||||1842|1350|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1842||||1842|477.8|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1842||||1842|1682|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1842||||1842|1800|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1842||||1842|546.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1842||||1842|491.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|1842||||1842|575|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1842||||1842|1178.88|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1842||||1842|677.03|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1842||||1842|526.02|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1842||||1842|1842|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1842||||1842|546.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1842||||1842|491.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1842||||1842|1842|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1842||||1842|546.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1842||||1842|546.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1842||||1842|1178.88|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1842||||1842|546.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|Self-pay|Self-pay|1842||||1842|644.7|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1842||||1842|546.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1842||||1842|181.11|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1842||||1842|361|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1842||||1842|491.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1842||||1842|491.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1842||||1842|361|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1842||||1842|491.15|1842|181.11
36032555|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC THORACENTESIS W/ IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1842||||1842|982.3|1842|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|AARP [1000]|AARP [100000]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|AETNA [1015]|AETNA [101529]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4209||||4209|1247.97|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4209||||4209|1247.97|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4209||||4209|2693.76|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4209||||4209|2031.28|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4209||||4209|1247.97|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4209||||4209|1247.97|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4209||||4209|1247.97|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4209||||4209|2693.76|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4209||||4209|1247.97|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|Self-pay|Self-pay|4209||||4209|1473.15|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4209||||4209|1247.97|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4209||||4209|181.11|2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4209||||4209||2693.76|181.11
36032556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4209||||4209||2693.76|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|AARP [1000]|AARP [100000]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|AETNA [1015]|AETNA [101529]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1127||||1127|334.16|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|BCBS [1155]|BCBS UTHCT [115568]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1127||||1127|334.16|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|CIGNA [1260]|CIGNA GWH [126023]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1127||||1127|721.28|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1127||||1127|1757.68|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1127||||1127|334.16|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1127||||1127|334.16|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1127||||1127|334.16|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1127||||1127|721.28|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1127||||1127|334.16|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|Self-pay|Self-pay|1127||||1127|394.45|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1127||||1127|334.16|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1127||||1127|181.11|1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1127||||1127||1757.68|181.11
36032557|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT INDWELLING CATH PLEURA W/ IMAGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1127||||1127||1757.68|181.11
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|AARP [1000]|AARP [100000]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|AETNA [1015]|AETNA [101529]|300||||300|300|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|88.95|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|0|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|88.95|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|0|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|192|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|150|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|300|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|88.95|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|300|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|88.95|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|88.95|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|192|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|88.95|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|Self-pay|Self-pay|300||||300|105|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|88.95|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|88.95|300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||300|88.95
36036000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INTRO NEEDLE/CATH VEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||300|88.95
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|AARP [1000]|AARP [100000]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|AETNA [1015]|AETNA [101529]|106||||106|46.75|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|106||||106|31.43|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|BCBS [1155]|BCBS UTHCT [115568]|106||||106|49.82|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|106||||106|0|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|106||||106|53|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|106||||106|66.78|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|106||||106|31.43|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|CIGNA [1260]|CIGNA GWH [126023]|106||||106|58.3|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|106||||106|73.14|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|106||||106|53|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|106||||106|46.75|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|106||||106|31.43|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|106||||106|46.75|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|106||||106|31.43|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|106||||106|31.43|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|106||||106|73.14|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|106||||106|31.43|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|Self-pay|Self-pay|106||||106|37.1|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|106||||106|31.43|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|106||||106|31.43|73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|106||||106||73.14|31.43
36036410|EAP|0300 - LABORATORY-GENERAL|HC VENPNCTR AGE>=3 REQRNG MD/QHP SKILL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|106||||106||73.14|31.43
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AARP [1000]|AARP [100000]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29|3.03|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AETNA [1015]|AETNA [101529]|29||||29|0|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29||||29|8.6|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BCBS UTHCT [115568]|29||||29|13.63|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29||||29|0|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29||||29|14.5|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29||||29|18.27|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29||||29|8.6|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|CIGNA [1260]|CIGNA GWH [126023]|29||||29|15.95|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|29||||29|20.01|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29||||29|3.75|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29||||29|0|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29||||29|8.6|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29||||29|0|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29|8.6|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|29||||29|8.6|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|29||||29|20.01|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29||||29|8.6|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|Self-pay|Self-pay|29||||29|10.15|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29||||29|8.6|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29||||29|8.6|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29||||29|3|20.01|3
36036415|EAP|0300 - LABORATORY-GENERAL|HC ROUTINE VENIPUNCTURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29||||29|6|20.01|3
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AARP [1000]|AARP [100000]|9||||9|3.79|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9||||9||6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AETNA [1015]|AETNA [101529]|9||||9|3.97|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9||||9|2.67|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9||||9||6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9||||9||6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS [1155]|BCBS UTHCT [115568]|9||||9|4.23|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9||||9|0|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9||||9|4.5|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9||||9|5.67|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9||||9|2.67|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9||||9||6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|CIGNA [1260]|CIGNA GWH [126023]|9||||9|4.95|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9||||9|6.21|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9||||9|4.5|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9||||9||6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9||||9|3.97|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9||||9|2.67|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9||||9||6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9||||9|3.97|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9||||9|2.67|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|9||||9|2.67|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9||||9|6.21|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9||||9|2.67|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|Self-pay|Self-pay|9||||9|3.15|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9||||9|2.67|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9||||9|2.67|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9||||9|3.79|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9||||9||6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9||||9||6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9||||9|3.79|6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9||||9||6.21|2.67
36036416|EAP|0300 - LABORATORY-GENERAL|HC CAPILLARY BLOOD DRAW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9||||9||6.21|2.67
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|AARP [1000]|AARP [100000]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|AETNA [1015]|AETNA [101529]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|397||||397|117.71|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|BCBS [1155]|BCBS UTHCT [115568]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|397||||397|117.71|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|CIGNA [1260]|CIGNA GWH [126023]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|397||||397|254.08|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|397||||397|432.3|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|397||||397|117.71|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|397||||397|117.71|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|397||||397|117.71|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|397||||397|254.08|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|397||||397|117.71|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|Self-pay|Self-pay|397||||397|138.95|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|397||||397|117.71|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|397||||397|117.71|432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|397||||397||432.3|117.71
36036468|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECT SPIDER VEINS LIMB/TRUNK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|397||||397||432.3|117.71
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|AARP [1000]|AARP [100000]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|AETNA [1015]|AETNA [101529]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|769||||769|228.01|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|BCBS [1155]|BCBS UTHCT [115568]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|769||||769|228.01|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|CIGNA [1260]|CIGNA GWH [126023]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|769||||769|492.16|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|769||||769|432.3|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|769||||769|228.01|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|769||||769|228.01|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|769||||769|228.01|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|769||||769|492.16|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|769||||769|228.01|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|Self-pay|Self-pay|769||||769|269.15|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|769||||769|228.01|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|769||||769|285.13|492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|769||||769||492.16|228.01
36036470|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJECTION THERAPY SINGLE VEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|769||||769||492.16|228.01
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|AARP [1000]|AARP [100000]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|AETNA [1015]|AETNA [101529]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|788||||788|233.64|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|BCBS [1155]|BCBS UTHCT [115568]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|788||||788|233.64|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|CIGNA [1260]|CIGNA GWH [126023]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|788||||788|504.32|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|788||||788|432.3|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|788||||788|233.64|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|788||||788|233.64|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|788||||788|233.64|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|788||||788|504.32|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|788||||788|233.64|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|Self-pay|Self-pay|788||||788|275.8|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|788||||788|233.64|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|788||||788|285.13|504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|788||||788||504.32|233.64
36036471|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCLEROTHERAPY 2+ VEINS SAME LEG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|788||||788||504.32|233.64
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|AARP [1000]|AARP [100000]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|AETNA [1015]|AETNA [101529]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6857||||6857|2033.1|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|BCBS [1155]|BCBS UTHCT [115568]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6857||||6857|2033.1|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|CIGNA [1260]|CIGNA GWH [126023]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6857||||6857|4388.48|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6857||||6857|3577.08|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6857||||6857|2033.1|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6857||||6857|2033.1|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6857||||6857|2033.1|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6857||||6857|4388.48|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6857||||6857|2033.1|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|Self-pay|Self-pay|6857||||6857|2399.95|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6857||||6857|2033.1|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6857||||6857|615.7|4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6857||||6857||4388.48|615.7
36036475|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION INCOMPETENT VEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6857||||6857||4388.48|615.7
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|AARP [1000]|AARP [100000]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|AETNA [1015]|AETNA [101529]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|855||||855|253.51|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|BCBS [1155]|BCBS UTHCT [115568]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|855||||855|0|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|855||||855|253.51|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|CIGNA [1260]|CIGNA GWH [126023]|855||||855|0|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|855||||855|547.2|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|855||||855|427.5|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|855||||855|253.51|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|855||||855|253.51|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|855||||855|253.51|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|855||||855|547.2|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|855||||855|253.51|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|Self-pay|Self-pay|855||||855|299.25|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|855||||855|253.51|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|855||||855|253.51|547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|855||||855||547.2|253.51
36036476|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABLATION ADDL INCOMPET VEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|855||||855||547.2|253.51
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|AARP [1000]|AARP [100000]|12422||||12422|2756|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12422||||12422|4369.13|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|AETNA [1015]|AETNA [101529]|12422||||12422|2200|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12422||||12422|3683.12|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12422||||12422|4325.87|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12422||||12422|4325.87|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|BCBS [1155]|BCBS UTHCT [115568]|12422||||12422||8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12422||||12422|3326.66|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12422||||12422||8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12422||||12422||8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12422||||12422|3683.12|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12422||||12422|4325.87|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|CIGNA [1260]|CIGNA GWH [126023]|12422||||12422||8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12422||||12422|7950.08|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12422||||12422|5962.96|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12422||||12422|4633.01|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12422||||12422|2200|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12422||||12422|3683.12|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12422||||12422|4325.87|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12422||||12422|2200|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12422||||12422|3683.12|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|12422||||12422|3683.12|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12422||||12422|7950.08|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12422||||12422|3683.12|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|Self-pay|Self-pay|12422||||12422|4347.7|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12422||||12422|3683.12|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12422||||12422|3683.12|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12422||||12422|2756|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12422||||12422|4325.87|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12422||||12422|4325.87|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12422||||12422|2756|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12422||||12422|4325.87|8651.74|2200
36036482|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE 1ST VEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12422||||12422|8651.74|8651.74|2200
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|AARP [1000]|AARP [100000]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|AETNA [1015]|AETNA [101529]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1408||||1408|417.47|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|BCBS [1155]|BCBS UTHCT [115568]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1408||||1408|0|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1408||||1408|417.47|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|CIGNA [1260]|CIGNA GWH [126023]|1408||||1408|0|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1408||||1408|901.12|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1408||||1408|704|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1408||||1408|417.47|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1408||||1408|417.47|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1408||||1408|417.47|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1408||||1408|901.12|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1408||||1408|417.47|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|Self-pay|Self-pay|1408||||1408|492.8|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1408||||1408|417.47|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1408||||1408|417.47|901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1408||||1408||901.12|417.47
36036483|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDOVEN ABLTI THER CHEM ADHESIVE SBSQ VEIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1408||||1408||901.12|417.47
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AARP [1000]|AARP [100000]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AETNA [1015]|AETNA [101529]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2074||||2074|614.94|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS [1155]|BCBS UTHCT [115568]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2074||||2074|614.94|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|CIGNA [1260]|CIGNA GWH [126023]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2074||||2074|1327.36|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2074||||2074|3577.08|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2074||||2074|614.94|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2074||||2074|614.94|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2074||||2074|614.94|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2074||||2074|1327.36|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2074||||2074|614.94|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|Self-pay|Self-pay|2074||||2074|725.9|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2074||||2074|614.94|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2074||||2074|285.13|3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2074||||2074||3577.08|285.13
36036556|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT NON-TUNNL CVC => 5 YRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2074||||2074||3577.08|285.13
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|AARP [1000]|AARP [100000]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|AETNA [1015]|AETNA [101529]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5567||||5567|1650.62|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|BCBS [1155]|BCBS UTHCT [115568]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5567||||5567|1650.62|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|CIGNA [1260]|CIGNA GWH [126023]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5567||||5567|3562.88|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5567||||5567|3577.08|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5567||||5567|1650.62|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5567||||5567|1650.62|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5567||||5567|1650.62|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5567||||5567|3562.88|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5567||||5567|1650.62|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|Self-pay|Self-pay|5567||||5567|1948.45|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5567||||5567|1650.62|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5567||||5567|437.85|3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5567||||5567||3577.08|437.85
36036561|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INST TUNNL W/SUBQ PORT =>5 YRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5567||||5567||3577.08|437.85
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|AARP [1000]|AARP [100000]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|AETNA [1015]|AETNA [101529]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|771||||771|228.6|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|BCBS [1155]|BCBS UTHCT [115568]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|771||||771|228.6|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|CIGNA [1260]|CIGNA GWH [126023]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|771||||771|493.44|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|771||||771|1757.68|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|771||||771|228.6|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|771||||771|228.6|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|771||||771|228.6|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|771||||771|493.44|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|771||||771|228.6|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|Self-pay|Self-pay|771||||771|269.85|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|771||||771|228.6|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|771||||771|285.13|1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|771||||771||1757.68|228.6
36036568|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT <5YRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|771||||771||1757.68|228.6
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|AARP [1000]|AARP [100000]|2347||||2347|361|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2347||||2347|1287.87|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|AETNA [1015]|AETNA [101529]|2347||||2347|2200|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2347||||2347|695.89|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2347||||2347|1275.12|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2347||||2347|1275.12|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|BCBS [1155]|BCBS UTHCT [115568]|2347||||2347|667|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2347||||2347|766.71|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2347||||2347|889|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2347||||2347|889|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2347||||2347|695.89|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2347||||2347|1275.12|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|CIGNA [1260]|CIGNA GWH [126023]|2347||||2347|575|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2347||||2347|1502.08|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2347||||2347|1757.68|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2347||||2347|1365.65|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2347||||2347|2200|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2347||||2347|695.89|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2347||||2347|1275.12|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2347||||2347|2200|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2347||||2347|695.89|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2347||||2347|695.89|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2347||||2347|1502.08|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2347||||2347|695.89|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|Self-pay|Self-pay|2347||||2347|821.45|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2347||||2347|695.89|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2347||||2347|285.13|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2347||||2347|361|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2347||||2347|1275.12|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2347||||2347|1275.12|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2347||||2347|361|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2347||||2347|1275.12|2550.23|285.13
36036569|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INS PICC W/O SUBQ PORT=>5YRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2347||||2347|2550.23|2550.23|285.13
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|AARP [1000]|AARP [100000]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|AETNA [1015]|AETNA [101529]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4069||||4069|1206.46|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|BCBS [1155]|BCBS UTHCT [115568]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4069||||4069|1206.46|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|CIGNA [1260]|CIGNA GWH [126023]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4069||||4069|2604.16|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4069||||4069|1757.68|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4069||||4069|1206.46|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4069||||4069|1206.46|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4069||||4069|1206.46|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4069||||4069|2604.16|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4069||||4069|1206.46|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|Self-pay|Self-pay|4069||||4069|1424.15|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4069||||4069|1206.46|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4069||||4069|381.79|2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4069||||4069||2604.16|381.79
36036573|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC  INSJ PICC W/RS&I 5 YR+|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4069||||4069||2604.16|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|AARP [1000]|AARP [100000]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|AETNA [1015]|AETNA [101529]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6522.51||||6522.51|1933.92|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|BCBS [1155]|BCBS UTHCT [115568]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6522.51||||6522.51|1933.92|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|CIGNA [1260]|CIGNA GWH [126023]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6522.51||||6522.51|4174.41|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6522.51||||6522.51|3577.08|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6522.51||||6522.51|1933.92|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6522.51||||6522.51|1933.92|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6522.51||||6522.51|1933.92|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6522.51||||6522.51|4174.41|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6522.51||||6522.51|1933.92|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|Self-pay|Self-pay|6522.51||||6522.51|2282.88|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6522.51||||6522.51|1933.92|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6522.51||||6522.51|381.79|4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6522.51||||6522.51||4174.41|381.79
36036582|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CMPLT REPLACE CATH W/SUBQ PORT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6522.51||||6522.51||4174.41|381.79
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AARP [1000]|AARP [100000]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AETNA [1015]|AETNA [101529]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|934||||934|276.93|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|BCBS [1155]|BCBS UTHCT [115568]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|934||||934|276.93|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|CIGNA [1260]|CIGNA GWH [126023]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|934||||934|597.76|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|934||||934|677.03|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|934||||934|276.93|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|934||||934|276.93|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|934||||934|276.93|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|934||||934|597.76|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|934||||934|276.93|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|Self-pay|Self-pay|934||||934|326.9|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|934||||934|276.93|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|934||||934|381.79|677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|934||||934||677.03|276.93
36036589|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/O SUBQ PORT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|934||||934||677.03|276.93
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|AARP [1000]|AARP [100000]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|AETNA [1015]|AETNA [101529]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2677||||2677|793.73|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|BCBS [1155]|BCBS UTHCT [115568]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2677||||2677|793.73|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|CIGNA [1260]|CIGNA GWH [126023]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2677||||2677|1713.28|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2677||||2677|1757.68|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2677||||2677|793.73|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2677||||2677|793.73|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2677||||2677|793.73|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2677||||2677|1713.28|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2677||||2677|793.73|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|Self-pay|Self-pay|2677||||2677|936.95|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2677||||2677|793.73|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2677||||2677|381.79|1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2677||||2677||1757.68|381.79
36036590|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RMVL TUNNL CATH W/SUBQ PORT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2677||||2677||1757.68|381.79
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|AARP [1000]|AARP [100000]|381.05||||381.05|119|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|381.05||||381.05|102.53|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|AETNA [1015]|AETNA [101529]|381.05||||381.05|381.05|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|381.05||||381.05|112.98|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|381.05||||381.05|101.52|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|381.05||||381.05|101.52|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|BCBS [1155]|BCBS UTHCT [115568]|381.05||||381.05|1350|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|381.05||||381.05|128.15|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|381.05||||381.05|1682|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|381.05||||381.05|1800|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|381.05||||381.05|112.98|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|381.05||||381.05|101.52|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|CIGNA [1260]|CIGNA GWH [126023]|381.05||||381.05|150|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|381.05||||381.05|243.87|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|381.05||||381.05|139.94|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|381.05||||381.05|108.73|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|381.05||||381.05|381.05|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|381.05||||381.05|112.98|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|381.05||||381.05|101.52|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|381.05||||381.05|381.05|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|381.05||||381.05|112.98|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|381.05||||381.05|112.98|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|381.05||||381.05|243.87|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|381.05||||381.05|112.98|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|Self-pay|Self-pay|381.05||||381.05|133.37|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|381.05||||381.05|112.98|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|381.05||||381.05|112.98|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|381.05||||381.05|119|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|381.05||||381.05|101.52|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|381.05||||381.05|101.52|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|381.05||||381.05|119|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|381.05||||381.05|101.52|1800|101.52
36036591|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLOOD COLLECTION FROM IMPL VAD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|381.05||||381.05|203.04|1800|101.52
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|AARP [1000]|AARP [100000]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|AETNA [1015]|AETNA [101529]|324||||324|324|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|324||||324|96.07|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|BCBS [1155]|BCBS UTHCT [115568]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|324||||324|96.07|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|CIGNA [1260]|CIGNA GWH [126023]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|324||||324|207.36|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|324||||324|139.94|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|324||||324|324|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|324||||324|96.07|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|324||||324|324|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|324||||324|96.07|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|324||||324|96.07|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|324||||324|207.36|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|324||||324|96.07|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|Self-pay|Self-pay|324||||324|113.4|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|324||||324|96.07|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|324||||324|96.07|324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|324||||324||324|96.07
36036592|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLLECT BLOOD FROM PICC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|324||||324||324|96.07
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|AARP [1000]|AARP [100000]|1031.99||||1031.99|119|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1031.99||||1031.99|284.62|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|AETNA [1015]|AETNA [101529]|1031.99||||1031.99|1031.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1031.99||||1031.99|305.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1031.99||||1031.99|281.8|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1031.99||||1031.99|281.8|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|BCBS [1155]|BCBS UTHCT [115568]|1031.99||||1031.99|1350|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1031.99||||1031.99|24.71|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1031.99||||1031.99|1682|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1031.99||||1031.99|1800|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1031.99||||1031.99|305.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1031.99||||1031.99|281.8|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|CIGNA [1260]|CIGNA GWH [126023]|1031.99||||1031.99|150|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1031.99||||1031.99|660.47|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1031.99||||1031.99|388.44|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1031.99||||1031.99|301.81|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1031.99||||1031.99|1031.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1031.99||||1031.99|305.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1031.99||||1031.99|281.8|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1031.99||||1031.99|1031.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1031.99||||1031.99|305.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1031.99||||1031.99|305.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1031.99||||1031.99|660.47|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1031.99||||1031.99|305.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|Self-pay|Self-pay|1031.99||||1031.99|361.2|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1031.99||||1031.99|305.99|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1031.99||||1031.99|285.13|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1031.99||||1031.99|119|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1031.99||||1031.99|281.8|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1031.99||||1031.99|281.8|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1031.99||||1031.99|119|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1031.99||||1031.99|281.8|1800|24.71
36036593|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DECLOT VASCULAR DEVICE BY THROMBOLYTIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1031.99||||1031.99|563.6|1800|24.71
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|AARP [1000]|AARP [100000]|518||||518|119|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|518||||518|186.38|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|AETNA [1015]|AETNA [101529]|518||||518|518|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|518||||518|153.59|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|518||||518|184.54|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|518||||518|184.54|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|BCBS [1155]|BCBS UTHCT [115568]|518||||518|1350|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|518||||518|66.54|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|518||||518|1682|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|518||||518|1800|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|518||||518|153.59|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|518||||518|184.54|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|CIGNA [1260]|CIGNA GWH [126023]|518||||518|518|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|518||||518|331.52|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|518||||518|254.38|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|518||||518|197.64|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|518||||518|518|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|518||||518|153.59|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|518||||518|184.54|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|518||||518|518|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|518||||518|153.59|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|518||||518|153.59|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|518||||518|331.52|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|518||||518|153.59|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|Self-pay|Self-pay|518||||518|181.3|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|518||||518|153.59|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|518||||518|285.13|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|518||||518|119|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|518||||518|184.54|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|518||||518|184.54|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|518||||518|119|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|518||||518|184.54|1800|66.54
36036598|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CNTRST EVAL EXST CVC DEV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|518||||518|369.07|1800|66.54
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AARP [1000]|AARP [100000]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AETNA [1015]|AETNA [101529]|182||||182|80.26|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182||||182|53.96|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BCBS UTHCT [115568]|182||||182|85.54|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182||||182|131.04|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182||||182|91|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182||||182|114.66|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182||||182|53.96|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|CIGNA [1260]|CIGNA GWH [126023]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182||||182|125.58|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|182||||182|139.94|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182||||182|80.26|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182||||182|53.96|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182||||182|80.26|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182||||182|53.96|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|182||||182|53.96|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182||||182|125.58|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182||||182|53.96|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|Self-pay|Self-pay|182||||182|63.7|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|182||||182|53.96|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182||||182|53.96|139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182||||182||139.94|53.96
36036600|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC PUNCTURE ARTERIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182||||182||139.94|53.96
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|AARP [1000]|AARP [100000]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|AETNA [1015]|AETNA [101529]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|668||||668|198.06|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|BCBS [1155]|BCBS UTHCT [115568]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|668||||668|0|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|668||||668|198.06|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|CIGNA [1260]|CIGNA GWH [126023]|668||||668|0|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|GROUP PENSION ADMIN [1450]|GPA [145000]|668||||668|427.52|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|668||||668|334|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|668||||668|198.06|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|668||||668|198.06|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|668||||668|198.06|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|PHCS [1780]|PHCS MULTIPLAN [178000]|668||||668|427.52|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|668||||668|198.06|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|Self-pay|Self-pay|668||||668|233.8|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|668||||668|198.06|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|668||||668|198.06|427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|668||||668||427.52|198.06
36036620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERC CATH/CANNULATION ART|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|668||||668||427.52|198.06
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|AARP [1000]|AARP [100000]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|AETNA [1015]|AETNA [101529]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|598||||598|177.31|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|BCBS [1155]|BCBS UTHCT [115568]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|598||||598|177.31|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|CIGNA [1260]|CIGNA GWH [126023]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|598||||598|382.72|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|598||||598|337.78|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|598||||598|177.31|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|598||||598|177.31|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|598||||598|177.31|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|598||||598|382.72|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|598||||598|177.31|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|Self-pay|Self-pay|598||||598|209.3|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|598||||598|177.31|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|598||||598|177.31|382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|598||||598||382.72|177.31
36036680|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PLCMNT NDL INTRAOSSEOUS INFUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|598||||598||382.72|177.31
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|AARP [1000]|AARP [100000]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|AETNA [1015]|AETNA [101529]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4922.31||||4922.31|1459.46|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|BCBS [1155]|BCBS UTHCT [115568]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4922.31||||4922.31|1459.46|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|CIGNA [1260]|CIGNA GWH [126023]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4922.31||||4922.31|3150.28|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4922.31||||4922.31|1758.75|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4922.31||||4922.31|1459.46|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4922.31||||4922.31|1459.46|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4922.31||||4922.31|1459.46|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4922.31||||4922.31|3150.28|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4922.31||||4922.31|1459.46|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|Self-pay|Self-pay|4922.31||||4922.31|1722.81|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4922.31||||4922.31|1459.46|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4922.31||||4922.31|285.13|3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4922.31||||4922.31||3150.28|285.13
36038220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW ASPIRATION ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4922.31||||4922.31||3150.28|285.13
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|AARP [1000]|AARP [100000]|4922.31||||4922.31|361|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4922.31||||4922.31|1288.66|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|AETNA [1015]|AETNA [101529]|4922.31||||4922.31|2200|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4922.31||||4922.31|1459.46|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4922.31||||4922.31|1275.9|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4922.31||||4922.31|1275.9|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|BCBS [1155]|BCBS UTHCT [115568]|4922.31||||4922.31|1350|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4922.31||||4922.31|83.95|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4922.31||||4922.31|1682|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4922.31||||4922.31|1800|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4922.31||||4922.31|1459.46|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4922.31||||4922.31|1275.9|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|CIGNA [1260]|CIGNA GWH [126023]|4922.31||||4922.31|575|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4922.31||||4922.31|3150.28|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4922.31||||4922.31|1758.75|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4922.31||||4922.31|1366.49|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4922.31||||4922.31|2200|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4922.31||||4922.31|1459.46|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4922.31||||4922.31|1275.9|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4922.31||||4922.31|2200|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4922.31||||4922.31|1459.46|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4922.31||||4922.31|1459.46|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4922.31||||4922.31|3150.28|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4922.31||||4922.31|1459.46|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|Self-pay|Self-pay|4922.31||||4922.31|1722.81|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4922.31||||4922.31|1459.46|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4922.31||||4922.31|285.13|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4922.31||||4922.31|361|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4922.31||||4922.31|1275.9|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4922.31||||4922.31|1275.9|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4922.31||||4922.31|361|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4922.31||||4922.31|1275.9|3150.28|83.95
36038221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) BONE MARROW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4922.31||||4922.31|2551.8|3150.28|83.95
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|AARP [1000]|AARP [100000]|4178||||4178|567|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4178||||4178|2170.66|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|AETNA [1015]|AETNA [101529]|4178||||4178|2200|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4178||||4178|1238.78|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4178||||4178|2149.17|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4178||||4178|2149.17|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|BCBS [1155]|BCBS UTHCT [115568]|4178||||4178||4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4178||||4178|92.66|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4178||||4178||4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4178||||4178||4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4178||||4178|1238.78|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4178||||4178|2149.17|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|CIGNA [1260]|CIGNA GWH [126023]|4178||||4178||4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4178||||4178|2673.92|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4178||||4178|2962.51|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4178||||4178|2301.76|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4178||||4178|2200|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4178||||4178|1238.78|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4178||||4178|2149.17|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4178||||4178|2200|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4178||||4178|1238.78|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4178||||4178|1238.78|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4178||||4178|2673.92|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4178||||4178|1238.78|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|Self-pay|Self-pay|4178||||4178|1462.3|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4178||||4178|1238.78|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4178||||4178|285.13|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4178||||4178|567|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4178||||4178|2149.17|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4178||||4178|2149.17|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4178||||4178|567|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4178||||4178|2149.17|4298.34|92.66
36038222|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BONE MARROW BIOPSY(S) & ASPIRATION(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4178||||4178|4298.34|4298.34|92.66
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|AARP [1000]|AARP [100000]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|AETNA [1015]|AETNA [101529]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|963||||963|285.53|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|BCBS [1155]|BCBS UTHCT [115568]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|963||||963|285.53|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|CIGNA [1260]|CIGNA GWH [126023]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|963||||963|616.32|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|963||||963|1758.75|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|963||||963|285.53|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|963||||963|285.53|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|963||||963|285.53|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|963||||963|616.32|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|963||||963|285.53|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|Self-pay|Self-pay|963||||963|337.05|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|963||||963|285.53|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|963||||963|285.13|1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|963||||963||1758.75|285.13
36038505|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY LYMPH NODE(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|963||||963||1758.75|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|AARP [1000]|AARP [100000]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|AETNA [1015]|AETNA [101529]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1192||||1192|353.43|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|BCBS [1155]|BCBS UTHCT [115568]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1192||||1192|353.43|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|CIGNA [1260]|CIGNA GWH [126023]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1192||||1192|762.88|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1192||||1192|565.45|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1192||||1192|353.43|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1192||||1192|353.43|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1192||||1192|353.43|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1192||||1192|762.88|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1192||||1192|353.43|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|Self-pay|Self-pay|1192||||1192|417.2|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1192||||1192|353.43|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1192||||1192|285.13|762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1192||||1192||762.88|285.13
36041000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE OF MOUTH LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1192||||1192||762.88|285.13
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|AARP [1000]|AARP [100000]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|AETNA [1015]|AETNA [101529]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|858||||858|254.4|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|BCBS [1155]|BCBS UTHCT [115568]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|858||||858|254.4|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|CIGNA [1260]|CIGNA GWH [126023]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|858||||858|549.12|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|858||||858|337.78|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|858||||858|254.4|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|858||||858|254.4|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|858||||858|254.4|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|858||||858|549.12|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|858||||858|254.4|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|Self-pay|Self-pay|858||||858|300.3|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|858||||858|254.4|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|858||||858|254.4|549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|858||||858||549.12|254.4
36041250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC RPR LAC<=2.5CM ANT 2/3 TONGUE/FLOOR MTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|858||||858||549.12|254.4
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|AARP [1000]|AARP [100000]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|AETNA [1015]|AETNA [101529]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|546||||546|161.89|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|BCBS [1155]|BCBS UTHCT [115568]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|546||||546|161.89|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|CIGNA [1260]|CIGNA GWH [126023]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|546||||546|349.44|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|546||||546|139.94|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|546||||546|161.89|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|546||||546|161.89|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|546||||546|161.89|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|546||||546|349.44|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|546||||546|161.89|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|Self-pay|Self-pay|546||||546|191.1|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|546||||546|161.89|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|546||||546|161.89|349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|546||||546||349.44|139.94
36041800|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN ABSC/CYST/HEMAT DENTOALV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|546||||546||349.44|139.94
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|AARP [1000]|AARP [100000]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|AETNA [1015]|AETNA [101529]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|775||||775|229.79|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|BCBS [1155]|BCBS UTHCT [115568]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|775||||775|229.79|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|CIGNA [1260]|CIGNA GWH [126023]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|GROUP PENSION ADMIN [1450]|GPA [145000]|775||||775|496|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|775||||775|777.46|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|775||||775|229.79|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|775||||775|229.79|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|775||||775|229.79|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|PHCS [1780]|PHCS MULTIPLAN [178000]|775||||775|496|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|775||||775|229.79|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|Self-pay|Self-pay|775||||775|271.25|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|775||||775|229.79|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|775||||775|285.13|777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|775||||775||777.46|229.79
36042400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEEDLE BIOPSY SALIVARY GLAND|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|775||||775||777.46|229.79
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|AARP [1000]|AARP [100000]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|AETNA [1015]|AETNA [101529]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|974||||974|288.79|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|BCBS [1155]|BCBS UTHCT [115568]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|974||||974|288.79|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|CIGNA [1260]|CIGNA GWH [126023]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|974||||974|623.36|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|974||||974|264.5|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|974||||974|288.79|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|974||||974|288.79|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|974||||974|288.79|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|974||||974|623.36|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|974||||974|288.79|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|Self-pay|Self-pay|974||||974|340.9|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|974||||974|288.79|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|974||||974|285.13|623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|974||||974||623.36|264.5
36042700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ABSCESS PERITONSILLAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|974||||974||623.36|264.5
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|AARP [1000]|AARP [100000]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|AETNA [1015]|AETNA [101529]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1998||||1998|592.41|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|BCBS [1155]|BCBS UTHCT [115568]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1998||||1998|592.41|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|CIGNA [1260]|CIGNA GWH [126023]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1998||||1998|1278.72|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1998||||1998|1012|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1998||||1998|592.41|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1998||||1998|592.41|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1998||||1998|592.41|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1998||||1998|1278.72|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1998||||1998|592.41|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|Self-pay|Self-pay|1998||||1998|699.3|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1998||||1998|592.41|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1998||||1998|285.13|1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1998||||1998||1278.72|285.13
36043200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY DIAGNOSTIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1998||||1998||1278.72|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|AARP [1000]|AARP [100000]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|AETNA [1015]|AETNA [101529]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1998||||1998|592.41|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BCBS UTHCT [115568]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1998||||1998|592.41|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|CIGNA [1260]|CIGNA GWH [126023]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1998||||1998|1278.72|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1998||||1998|2031.28|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1998||||1998|592.41|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1998||||1998|592.41|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1998||||1998|592.41|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1998||||1998|1278.72|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1998||||1998|592.41|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|Self-pay|Self-pay|1998||||1998|699.3|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1998||||1998|592.41|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1998||||1998|285.13|2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1998||||1998||2031.28|285.13
36043202|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/BIOPSY(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1998||||1998||2031.28|285.13
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|AARP [1000]|AARP [100000]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|AETNA [1015]|AETNA [101529]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|Self-pay|Self-pay|2916||||2916|1020.6|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|437.85|2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916||2031.28|437.85
36043214|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BALLOON DILATION ESOPHAGUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916||2031.28|437.85
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|AARP [1000]|AARP [100000]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|AETNA [1015]|AETNA [101529]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|Self-pay|Self-pay|2916||||2916|1020.6|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|285.13|2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916||2031.28|285.13
36043226|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIL ESOPHAGUS BALLOON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916||2031.28|285.13
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|AARP [1000]|AARP [100000]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|AETNA [1015]|AETNA [101529]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5308||||5308|1573.82|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|BCBS [1155]|BCBS UTHCT [115568]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5308||||5308|1573.82|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|CIGNA [1260]|CIGNA GWH [126023]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5308||||5308|3397.12|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5308||||5308|3850.99|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5308||||5308|1573.82|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5308||||5308|1573.82|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5308||||5308|1573.82|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5308||||5308|3397.12|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5308||||5308|1573.82|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|Self-pay|Self-pay|5308||||5308|1857.8|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5308||||5308|1573.82|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5308||||5308|853.48|3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5308||||5308||3850.99|853.48
36043229|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY LESION ABLATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5308||||5308||3850.99|853.48
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|AARP [1000]|AARP [100000]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|AETNA [1015]|AETNA [101529]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|Self-pay|Self-pay|2916||||2916|1020.6|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|285.13|2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916||2031.28|285.13
36043231|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ESOPHAGOSCOPY W/ULTRASOUND EXAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916||2031.28|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|AARP [1000]|AARP [100000]|1998||||1998|567|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1998||||1998|741.5|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|AETNA [1015]|AETNA [101529]|1998||||1998|1998|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1998||||1998|592.41|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1998||||1998|734.16|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1998||||1998|734.16|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|BCBS [1155]|BCBS UTHCT [115568]|1998||||1998|667|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1998||||1998|579.92|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1998||||1998|889|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1998||||1998|889|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1998||||1998|592.41|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1998||||1998|734.16|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|CIGNA [1260]|CIGNA GWH [126023]|1998||||1998|575|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1998||||1998|1278.72|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1998||||1998|1012|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1998||||1998|786.28|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1998||||1998|1998|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1998||||1998|592.41|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1998||||1998|734.16|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1998||||1998|1998|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1998||||1998|592.41|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1998||||1998|592.41|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1998||||1998|1278.72|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1998||||1998|592.41|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|Self-pay|Self-pay|1998||||1998|699.3|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1998||||1998|592.41|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1998||||1998|285.13|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1998||||1998|567|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1998||||1998|734.16|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1998||||1998|734.16|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1998||||1998|567|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1998||||1998|734.16|1998|285.13
36043235|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DIAGNOSTIC BRUSH WASH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1998||||1998|1468.32|1998|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|AARP [1000]|AARP [100000]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|AETNA [1015]|AETNA [101529]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2443||||2443|724.35|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|BCBS [1155]|BCBS UTHCT [115568]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2443||||2443|724.35|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|CIGNA [1260]|CIGNA GWH [126023]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2443||||2443|1563.52|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2443||||2443|1012|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2443||||2443|724.35|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2443||||2443|724.35|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2443||||2443|724.35|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2443||||2443|1563.52|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2443||||2443|724.35|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|Self-pay|Self-pay|2443||||2443|855.05|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2443||||2443|724.35|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2443||||2443|285.13|1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2443||||2443||1563.52|285.13
36043236|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/SUBMUCOSAL INJECTION(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2443||||2443||1563.52|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|AARP [1000]|AARP [100000]|2916||||2916|567|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916|1488.33|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|AETNA [1015]|AETNA [101529]|2916||||2916|2200|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916|1473.6|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916|1473.6|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916|893|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916|1113.36|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916|1191|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916|1191|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916|1473.6|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916|825|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916|1578.22|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916|2200|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916|1473.6|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916|2200|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|Self-pay|Self-pay|2916||||2916|1020.6|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|285.13|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916|567|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916|1473.6|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916|1473.6|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916|567|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916|1473.6|2947.19|285.13
36043237|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENDO US ESOPH STOM DUOD ADJAC STRUCT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916|2947.19|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|AARP [1000]|AARP [100000]|2916||||2916|567|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916|1488.33|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|AETNA [1015]|AETNA [101529]|2916||||2916|2200|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916|1473.6|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916|1473.6|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916|893|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916|1113.36|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916|1191|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916|1191|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916|1473.6|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916|825|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916|1578.22|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916|2200|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916|1473.6|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916|2200|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|Self-pay|Self-pay|2916||||2916|1020.6|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|285.13|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916|567|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916|1473.6|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916|1473.6|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916|567|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916|1473.6|2947.19|285.13
36043238|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM/FN BX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916|2947.19|2947.19|285.13
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|AARP [1000]|AARP [100000]|1998||||1998|567|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1998||||1998|741.5|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|AETNA [1015]|AETNA [101529]|1998||||1998|1998|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1998||||1998|592.41|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1998||||1998|734.16|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1998||||1998|734.16|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|BCBS [1155]|BCBS UTHCT [115568]|1998||||1998|893|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1998||||1998|579.92|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1998||||1998|1191|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1998||||1998|1191|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1998||||1998|592.41|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1998||||1998|734.16|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|CIGNA [1260]|CIGNA GWH [126023]|1998||||1998|825|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1998||||1998|1278.72|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1998||||1998|1012|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1998||||1998|786.28|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1998||||1998|1998|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1998||||1998|592.41|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1998||||1998|734.16|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1998||||1998|1998|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1998||||1998|592.41|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1998||||1998|592.41|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1998||||1998|1278.72|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1998||||1998|592.41|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|Self-pay|Self-pay|1998||||1998|699.3|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1998||||1998|592.41|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1998||||1998|381.79|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1998||||1998|567|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1998||||1998|734.16|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1998||||1998|734.16|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1998||||1998|567|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1998||||1998|734.16|1998|381.79
36043239|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BIOPSY SINGLE/MULTIPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1998||||1998|1468.32|1998|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|AARP [1000]|AARP [100000]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|AETNA [1015]|AETNA [101529]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|Self-pay|Self-pay|2916||||2916|1020.6|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|381.79|2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916||2031.28|381.79
36043242|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC UPPER GI ENDOSCOPY W/US FN BX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|AARP [1000]|AARP [100000]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|AETNA [1015]|AETNA [101529]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|Self-pay|Self-pay|2916||||2916|1020.6|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|381.79|2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916||2031.28|381.79
36043244|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/BAND ESOPH/GASTRIC VARICES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916||2031.28|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|AARP [1000]|AARP [100000]|2916||||2916|567|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916|1488.33|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|AETNA [1015]|AETNA [101529]|2916||||2916|2200|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916|1473.6|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916|1473.6|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916|893|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916|1113.36|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916|1191|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916|1191|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916|1473.6|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916|825|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916|1578.22|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916|2200|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916|1473.6|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916|2200|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|Self-pay|Self-pay|2916||||2916|1020.6|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|381.79|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916|567|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916|1473.6|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916|1473.6|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916|567|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916|1473.6|2947.19|381.79
36043245|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD DILATE GASTRIC/DUOD STRICTURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916|2947.19|2947.19|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AARP [1000]|AARP [100000]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AETNA [1015]|AETNA [101529]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3594||||3594|1065.62|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS [1155]|BCBS UTHCT [115568]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3594||||3594|1065.62|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|CIGNA [1260]|CIGNA GWH [126023]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3594||||3594|2300.16|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3594||||3594|2031.28|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3594||||3594|1065.62|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3594||||3594|1065.62|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3594||||3594|1065.62|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3594||||3594|2300.16|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3594||||3594|1065.62|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|Self-pay|Self-pay|3594||||3594|1257.9|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3594||||3594|1065.62|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3594||||3594|381.79|2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3594||||3594||2300.16|381.79
36043246|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/PEG PLACEMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3594||||3594||2300.16|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|AARP [1000]|AARP [100000]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|AETNA [1015]|AETNA [101529]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1998||||1998|592.41|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|BCBS [1155]|BCBS UTHCT [115568]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1998||||1998|592.41|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|CIGNA [1260]|CIGNA GWH [126023]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1998||||1998|1278.72|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1998||||1998|1012|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1998||||1998|592.41|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1998||||1998|592.41|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1998||||1998|592.41|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1998||||1998|1278.72|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1998||||1998|592.41|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|Self-pay|Self-pay|1998||||1998|699.3|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1998||||1998|592.41|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1998||||1998|381.79|1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1998||||1998||1278.72|381.79
36043247|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/REMOVE FB(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1998||||1998||1278.72|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|AARP [1000]|AARP [100000]|1998||||1998|567|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1998||||1998|741.5|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|AETNA [1015]|AETNA [101529]|1998||||1998|1998|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1998||||1998|592.41|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1998||||1998|734.16|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1998||||1998|734.16|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|BCBS [1155]|BCBS UTHCT [115568]|1998||||1998|893|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1998||||1998|579.92|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1998||||1998|1191|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1998||||1998|1191|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1998||||1998|592.41|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1998||||1998|734.16|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|CIGNA [1260]|CIGNA GWH [126023]|1998||||1998|825|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1998||||1998|1278.72|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1998||||1998|1012|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1998||||1998|786.28|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1998||||1998|1998|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1998||||1998|592.41|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1998||||1998|734.16|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1998||||1998|1998|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1998||||1998|592.41|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1998||||1998|592.41|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1998||||1998|1278.72|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1998||||1998|592.41|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|Self-pay|Self-pay|1998||||1998|699.3|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1998||||1998|592.41|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1998||||1998|381.79|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1998||||1998|567|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1998||||1998|734.16|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1998||||1998|734.16|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1998||||1998|567|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1998||||1998|734.16|1998|381.79
36043248|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ESOPH DILAT OVER GUIDE WIRE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1998||||1998|1468.32|1998|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|AARP [1000]|AARP [100000]|2916||||2916|567|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916|1488.33|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|AETNA [1015]|AETNA [101529]|2916||||2916|2200|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916|1473.6|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916|1473.6|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916|893|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916|1113.36|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916|1191|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916|1191|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916|1473.6|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916|825|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916|1578.22|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916|2200|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916|1473.6|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916|2200|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|Self-pay|Self-pay|2916||||2916|1020.6|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|381.79|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916|567|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916|1473.6|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916|1473.6|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916|567|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916|1473.6|2947.19|381.79
36043249|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD BALLOON DILATION ESOPHAGUS <30 MM DIAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916|2947.19|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|AARP [1000]|AARP [100000]|2916||||2916|567|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916|1488.33|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|AETNA [1015]|AETNA [101529]|2916||||2916|2200|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916|1473.6|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916|1473.6|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916|893|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916|1113.36|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916|1191|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916|1191|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916|1473.6|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916|825|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916|1578.22|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916|2200|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916|1473.6|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916|2200|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|Self-pay|Self-pay|2916||||2916|1020.6|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|381.79|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916|567|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916|1473.6|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916|1473.6|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916|567|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916|1473.6|2947.19|381.79
36043251|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD REMOVE TUMOR/POLYP/LESION SNARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916|2947.19|2947.19|381.79
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|AARP [1000]|AARP [100000]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|AETNA [1015]|AETNA [101529]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|Self-pay|Self-pay|2916||||2916|1020.6|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|285.13|2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916||2031.28|285.13
36043254|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD ENDO MUCOSAL RESECTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916||2031.28|285.13
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|AARP [1000]|AARP [100000]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|AETNA [1015]|AETNA [101529]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|Self-pay|Self-pay|2916||||2916|1020.6|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|381.79|2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916||2031.28|381.79
36043255|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/CONTROL OF BLEED ANY METHOD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916||2031.28|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|AARP [1000]|AARP [100000]|2916||||2916|567|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916|1488.33|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|AETNA [1015]|AETNA [101529]|2916||||2916|2200|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916|1473.6|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916|1473.6|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916|1022|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916|1113.36|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916|1362|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916|1362|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916|1473.6|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916|975|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916|1578.22|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916|2200|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916|1473.6|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916|2200|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|Self-pay|Self-pay|2916||||2916|1020.6|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|381.79|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916|567|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916|1473.6|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916|1473.6|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916|567|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916|1473.6|2947.19|381.79
36043259|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ULTRASOUND EXAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916|2947.19|2947.19|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|AARP [1000]|AARP [100000]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|AETNA [1015]|AETNA [101529]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5308||||5308|1573.82|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|BCBS [1155]|BCBS UTHCT [115568]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5308||||5308|1573.82|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|CIGNA [1260]|CIGNA GWH [126023]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5308||||5308|3397.12|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5308||||5308|3850.99|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5308||||5308|1573.82|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5308||||5308|1573.82|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5308||||5308|1573.82|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5308||||5308|3397.12|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5308||||5308|1573.82|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|Self-pay|Self-pay|5308||||5308|1857.8|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5308||||5308|1573.82|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5308||||5308|381.79|3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5308||||5308||3850.99|381.79
36043260|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|AARP [1000]|AARP [100000]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|AETNA [1015]|AETNA [101529]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5308||||5308|1573.82|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|BCBS [1155]|BCBS UTHCT [115568]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5308||||5308|1573.82|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|CIGNA [1260]|CIGNA GWH [126023]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5308||||5308|3397.12|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5308||||5308|3850.99|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5308||||5308|1573.82|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5308||||5308|1573.82|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5308||||5308|1573.82|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5308||||5308|3397.12|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5308||||5308|1573.82|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|Self-pay|Self-pay|5308||||5308|1857.8|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5308||||5308|1573.82|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5308||||5308|381.79|3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5308||||5308||3850.99|381.79
36043261|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/BIOPSY(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|AARP [1000]|AARP [100000]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|AETNA [1015]|AETNA [101529]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5308||||5308|1573.82|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|BCBS [1155]|BCBS UTHCT [115568]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5308||||5308|1573.82|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|CIGNA [1260]|CIGNA GWH [126023]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5308||||5308|3397.12|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5308||||5308|3850.99|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5308||||5308|1573.82|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5308||||5308|1573.82|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5308||||5308|1573.82|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5308||||5308|3397.12|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5308||||5308|1573.82|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|Self-pay|Self-pay|5308||||5308|1857.8|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5308||||5308|1573.82|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5308||||5308|381.79|3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5308||||5308||3850.99|381.79
36043262|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/SPHINCTEROTOMY/PAPILLOTOMY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|AARP [1000]|AARP [100000]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|AETNA [1015]|AETNA [101529]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5308||||5308|1573.82|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|BCBS [1155]|BCBS UTHCT [115568]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5308||||5308|1573.82|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|CIGNA [1260]|CIGNA GWH [126023]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5308||||5308|3397.12|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5308||||5308|3850.99|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5308||||5308|1573.82|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5308||||5308|1573.82|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5308||||5308|1573.82|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5308||||5308|3397.12|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5308||||5308|1573.82|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|Self-pay|Self-pay|5308||||5308|1857.8|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5308||||5308|1573.82|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5308||||5308|381.79|3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5308||||5308||3850.99|381.79
36043264|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE CALCULI/DEBRIS BILI PANC DUCT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5308||||5308||3850.99|381.79
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|AARP [1000]|AARP [100000]|2916||||2916|567|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916|1488.33|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|AETNA [1015]|AETNA [101529]|2916||||2916|2200|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916|1473.6|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916|1473.6|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916|1350|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916|1113.36|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916|1682|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916|1800|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916|1473.6|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916|1500|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916|1578.22|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916|2200|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916|1473.6|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916|2200|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|Self-pay|Self-pay|2916||||2916|1020.6|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|437.85|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916|567|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916|1473.6|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916|1473.6|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916|567|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916|1473.6|2947.19|437.85
36043270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EGD W/ABLATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916|2947.19|2947.19|437.85
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|AARP [1000]|AARP [100000]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|AETNA [1015]|AETNA [101529]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4449||||4449|1319.13|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|BCBS [1155]|BCBS UTHCT [115568]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4449||||4449|0|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4449||||4449|1319.13|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|CIGNA [1260]|CIGNA GWH [126023]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4449||||4449|2847.36|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4449||||4449|2224.5|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4449||||4449|1319.13|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4449||||4449|1319.13|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4449||||4449|1319.13|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4449||||4449|2847.36|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4449||||4449|1319.13|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|Self-pay|Self-pay|4449||||4449|1557.15|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4449||||4449|1319.13|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4449||||4449|1319.13|2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4449||||4449||2847.36|1319.13
36043273|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SCOPE DIRCT VISUAL BILE/PANCR DCT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4449||||4449||2847.36|1319.13
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|AARP [1000]|AARP [100000]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|AETNA [1015]|AETNA [101529]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9685||||9685|2871.6|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|BCBS [1155]|BCBS UTHCT [115568]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9685||||9685|2871.6|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|CIGNA [1260]|CIGNA GWH [126023]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9685||||9685|6198.4|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9685||||9685|6285.65|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9685||||9685|2871.6|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9685||||9685|2871.6|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|9685||||9685|2871.6|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9685||||9685|6198.4|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9685||||9685|2871.6|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|Self-pay|Self-pay|9685||||9685|3389.75|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9685||||9685|2871.6|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9685||||9685|853.48|6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9685||||9685||6285.65|853.48
36043274|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP W/STENT PLACEMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9685||||9685||6285.65|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|AARP [1000]|AARP [100000]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|AETNA [1015]|AETNA [101529]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5308||||5308|1573.82|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|BCBS [1155]|BCBS UTHCT [115568]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5308||||5308|1573.82|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|CIGNA [1260]|CIGNA GWH [126023]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5308||||5308|3397.12|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5308||||5308|3850.99|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5308||||5308|1573.82|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5308||||5308|1573.82|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5308||||5308|1573.82|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5308||||5308|3397.12|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5308||||5308|1573.82|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|Self-pay|Self-pay|5308||||5308|1857.8|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5308||||5308|1573.82|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5308||||5308|853.48|3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5308||||5308||3850.99|853.48
36043275|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP REMOVE FOREIGN BODY(S)/STENT(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5308||||5308||3850.99|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|AARP [1000]|AARP [100000]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|AETNA [1015]|AETNA [101529]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9685||||9685|2871.6|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|BCBS [1155]|BCBS UTHCT [115568]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9685||||9685|2871.6|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|CIGNA [1260]|CIGNA GWH [126023]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|9685||||9685|6198.4|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9685||||9685|6285.65|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9685||||9685|2871.6|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9685||||9685|2871.6|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|9685||||9685|2871.6|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|9685||||9685|6198.4|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9685||||9685|2871.6|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|Self-pay|Self-pay|9685||||9685|3389.75|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9685||||9685|2871.6|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9685||||9685|853.48|6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9685||||9685||6285.65|853.48
36043276|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ERCP STENT EXCHANGE W/DILATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9685||||9685||6285.65|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|AARP [1000]|AARP [100000]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|AETNA [1015]|AETNA [101529]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5308||||5308|1573.82|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|BCBS [1155]|BCBS UTHCT [115568]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5308||||5308|1573.82|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|CIGNA [1260]|CIGNA GWH [126023]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5308||||5308|3397.12|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5308||||5308|3850.99|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5308||||5308|1573.82|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5308||||5308|1573.82|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5308||||5308|1573.82|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5308||||5308|3397.12|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5308||||5308|1573.82|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|Self-pay|Self-pay|5308||||5308|1857.8|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5308||||5308|1573.82|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5308||||5308|853.48|3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5308||||5308||3850.99|853.48
36043277|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ERCP W/BALLOON DILATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5308||||5308||3850.99|853.48
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AARP [1000]|AARP [100000]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AETNA [1015]|AETNA [101529]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|239||||239|70.86|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|BCBS [1155]|BCBS UTHCT [115568]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|239||||239|70.86|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|CIGNA [1260]|CIGNA GWH [126023]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|239||||239|152.96|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|239||||239|337.78|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|239||||239|70.86|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|239||||239|70.86|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|239||||239|70.86|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|239||||239|152.96|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|239||||239|70.86|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|Self-pay|Self-pay|239||||239|83.65|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|239||||239|70.86|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|239||||239|239|337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|239||||239||337.78|70.86
36043752|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NASO/ORO-GASTRIC TUBE PLMT REQ PHYS&FLUOR GDNCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|239||||239||337.78|70.86
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|AARP [1000]|AARP [100000]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|AETNA [1015]|AETNA [101529]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|625||||625|185.31|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|BCBS [1155]|BCBS UTHCT [115568]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|625||||625|185.31|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|CIGNA [1260]|CIGNA GWH [126023]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|625||||625|400|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|625||||625|332.68|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|625||||625|185.31|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|625||||625|185.31|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|625||||625|185.31|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|625||||625|400|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|625||||625|185.31|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|Self-pay|Self-pay|625||||625|218.75|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|625||||625|185.31|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|625||||625|285.13|400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|625||||625||400|185.31
36043762|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|625||||625||400|185.31
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|AARP [1000]|AARP [100000]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|AETNA [1015]|AETNA [101529]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1998||||1998|592.41|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|BCBS [1155]|BCBS UTHCT [115568]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1998||||1998|592.41|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|CIGNA [1260]|CIGNA GWH [126023]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1998||||1998|1278.72|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1998||||1998|2031.28|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1998||||1998|592.41|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1998||||1998|592.41|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1998||||1998|592.41|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1998||||1998|1278.72|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1998||||1998|592.41|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|Self-pay|Self-pay|1998||||1998|699.3|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1998||||1998|592.41|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1998||||1998|381.79|2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1998||||1998||2031.28|381.79
36044360|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SM INTEST ENDO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1998||||1998||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|AARP [1000]|AARP [100000]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|AETNA [1015]|AETNA [101529]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2930||||2930|868.75|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|BCBS [1155]|BCBS UTHCT [115568]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2930||||2930|868.75|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|CIGNA [1260]|CIGNA GWH [126023]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2930||||2930|1875.2|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2930||||2930|2031.28|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2930||||2930|868.75|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2930||||2930|868.75|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2930||||2930|868.75|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2930||||2930|1875.2|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2930||||2930|868.75|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|Self-pay|Self-pay|2930||||2930|1025.5|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2930||||2930|868.75|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2930||||2930|381.79|2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2930||||2930||2031.28|381.79
36044369|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN ABLTJ LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2930||||2930||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|AARP [1000]|AARP [100000]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|AETNA [1015]|AETNA [101529]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2916||||2916|864.59|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|BCBS [1155]|BCBS UTHCT [115568]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2916||||2916|864.59|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|CIGNA [1260]|CIGNA GWH [126023]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2916||||2916|1866.24|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2916||||2916|2031.28|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2916||||2916|864.59|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2916||||2916|864.59|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2916||||2916|864.59|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2916||||2916|1866.24|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2916||||2916|864.59|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|Self-pay|Self-pay|2916||||2916|1020.6|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2916||||2916|864.59|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2916||||2916|381.79|2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2916||||2916||2031.28|381.79
36044373|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ENTEROSCOPY > 2ND PRTN CONV GSTRST TUBE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2916||||2916||2031.28|381.79
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|AARP [1000]|AARP [100000]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|AETNA [1015]|AETNA [101529]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|992.06|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|Self-pay|Self-pay|2018||||2018|706.3|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|285.13|1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||1291.52|285.13
36044388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA DX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||1291.52|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|AARP [1000]|AARP [100000]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|AETNA [1015]|AETNA [101529]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|Self-pay|Self-pay|2018||||2018|706.3|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|285.13|1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||1296.2|285.13
36044389|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY THRU STOMA W/BIOPSY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||1296.2|285.13
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|AARP [1000]|AARP [100000]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|AETNA [1015]|AETNA [101529]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|Self-pay|Self-pay|2018||||2018|706.3|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|381.79|1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||1296.2|381.79
36044394|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/RMVL TUM POLYP/OTH LES SNAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||1296.2|381.79
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|AARP [1000]|AARP [100000]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|AETNA [1015]|AETNA [101529]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|Self-pay|Self-pay|2018||||2018|706.3|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|598.34|1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||1296.2|598.34
36044401|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA ABLATION LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||1296.2|598.34
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|AARP [1000]|AARP [100000]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|AETNA [1015]|AETNA [101529]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2363||||2363|700.63|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|BCBS [1155]|BCBS UTHCT [115568]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2363||||2363|700.63|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|CIGNA [1260]|CIGNA GWH [126023]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2363||||2363|1512.32|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2363||||2363|1296.2|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2363||||2363|700.63|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2363||||2363|700.63|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2363||||2363|700.63|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2363||||2363|1512.32|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2363||||2363|700.63|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|Self-pay|Self-pay|2363||||2363|827.05|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2363||||2363|700.63|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2363||||2363|285.13|1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2363||||2363||1512.32|285.13
36044404|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY STOMA W/SUBMUCOSAL INJECTION(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2363||||2363||1512.32|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|AARP [1000]|AARP [100000]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|AETNA [1015]|AETNA [101529]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1290||||1290|382.49|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|BCBS [1155]|BCBS UTHCT [115568]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1290||||1290|382.49|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|CIGNA [1260]|CIGNA GWH [126023]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1290||||1290|825.6|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1290||||1290|992.06|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1290||||1290|382.49|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1290||||1290|382.49|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1290||||1290|382.49|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1290||||1290|825.6|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1290||||1290|382.49|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|Self-pay|Self-pay|1290||||1290|451.5|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1290||||1290|382.49|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1290||||1290|285.13|992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1290||||1290||992.06|285.13
36045300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PROCTOSIGMOIDOSCOPY RIGID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1290||||1290||992.06|285.13
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|AARP [1000]|AARP [100000]|2122||||2122|361|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2122||||2122|726.9|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|AETNA [1015]|AETNA [101529]|2122||||2122|2122|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2122||||2122|629.17|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2122||||2122|719.7|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2122||||2122|719.7|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|BCBS [1155]|BCBS UTHCT [115568]|2122||||2122|1350|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2122||||2122|108.1|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2122||||2122|1682|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2122||||2122|1800|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2122||||2122|629.17|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2122||||2122|719.7|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|CIGNA [1260]|CIGNA GWH [126023]|2122||||2122|575|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2122||||2122|1358.08|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2122||||2122|992.06|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2122||||2122|770.8|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2122||||2122|2122|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2122||||2122|629.17|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2122||||2122|719.7|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2122||||2122|2122|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2122||||2122|629.17|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2122||||2122|629.17|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2122||||2122|1358.08|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2122||||2122|629.17|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|Self-pay|Self-pay|2122||||2122|742.7|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2122||||2122|629.17|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2122||||2122|285.13|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2122||||2122|361|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2122||||2122|719.7|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2122||||2122|719.7|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2122||||2122|361|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2122||||2122|719.7|2122|108.1
36045330|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY DX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2122||||2122|1439.4|2122|108.1
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|AARP [1000]|AARP [100000]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|AETNA [1015]|AETNA [101529]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1320||||1320|391.38|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BCBS UTHCT [115568]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1320||||1320|391.38|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|CIGNA [1260]|CIGNA GWH [126023]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1320||||1320|844.8|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1320||||1320|992.06|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1320||||1320|391.38|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1320||||1320|391.38|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1320||||1320|391.38|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1320||||1320|844.8|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1320||||1320|391.38|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|Self-pay|Self-pay|1320||||1320|462|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1320||||1320|391.38|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1320||||1320|285.13|992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1320||||1320||992.06|285.13
36045331|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/BIOPSY(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1320||||1320||992.06|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|AARP [1000]|AARP [100000]|2774||||2774|361|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2774||||2774|726.9|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|AETNA [1015]|AETNA [101529]|2774||||2774|2200|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2774||||2774|822.49|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2774||||2774|719.7|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2774||||2774|719.7|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|BCBS [1155]|BCBS UTHCT [115568]|2774||||2774|667|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2774||||2774|553.78|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2774||||2774|889|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2774||||2774|889|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2774||||2774|822.49|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2774||||2774|719.7|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|CIGNA [1260]|CIGNA GWH [126023]|2774||||2774|575|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2774||||2774|1775.36|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2774||||2774|992.06|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2774||||2774|770.8|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2774||||2774|2200|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2774||||2774|822.49|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2774||||2774|719.7|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2774||||2774|2200|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2774||||2774|822.49|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2774||||2774|822.49|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2774||||2774|1775.36|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2774||||2774|822.49|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|Self-pay|Self-pay|2774||||2774|970.9|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2774||||2774|822.49|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2774||||2774|285.13|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2774||||2774|361|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2774||||2774|719.7|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2774||||2774|719.7|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2774||||2774|361|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2774||||2774|719.7|2200|285.13
36045335|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/SUBMUCOSAL INJ(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2774||||2774|1439.4|2200|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|AARP [1000]|AARP [100000]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|AETNA [1015]|AETNA [101529]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|Self-pay|Self-pay|2018||||2018|706.3|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|285.13|1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||1296.2|285.13
36045338|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY W/REMOVE BY SNARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||1296.2|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|AARP [1000]|AARP [100000]|2018||||2018|567|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018|726.9|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|AETNA [1015]|AETNA [101529]|2018||||2018|2018|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018|719.7|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018|719.7|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018|667|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018|730.38|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018|889|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018|889|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018|719.7|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018|575|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|992.06|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018|770.8|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018|2018|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018|719.7|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018|2018|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|Self-pay|Self-pay|2018||||2018|706.3|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|285.13|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018|567|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018|719.7|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018|719.7|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018|567|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018|719.7|2018|285.13
36045341|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FLEX SIGMOIDOSCOPY W/EUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018|1439.4|2018|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|AARP [1000]|AARP [100000]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|AETNA [1015]|AETNA [101529]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4453||||4453|1320.31|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|BCBS [1155]|BCBS UTHCT [115568]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4453||||4453|1320.31|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|CIGNA [1260]|CIGNA GWH [126023]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4453||||4453|2849.92|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4453||||4453|1296.2|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4453||||4453|1320.31|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4453||||4453|1320.31|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4453||||4453|1320.31|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4453||||4453|2849.92|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4453||||4453|1320.31|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|Self-pay|Self-pay|4453||||4453|1558.55|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4453||||4453|1320.31|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4453||||4453|285.13|2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4453||||4453||2849.92|285.13
36045342|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOID W/FNA BIOPSY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4453||||4453||2849.92|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|AARP [1000]|AARP [100000]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|AETNA [1015]|AETNA [101529]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|Self-pay|Self-pay|2018||||2018|706.3|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|285.13|1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||1296.2|285.13
36045346|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEX W/ABLATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||1296.2|285.13
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|AARP [1000]|AARP [100000]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|AETNA [1015]|AETNA [101529]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|3054.24|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|Self-pay|Self-pay|2018||||2018|706.3|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|437.85|3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||3054.24|437.85
36045349|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SGMDSC FLX W/ENDOSCOPIC MUCOSAL RESECTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||3054.24|437.85
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|AARP [1000]|AARP [100000]|2018||||2018|567|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018|726.9|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|AETNA [1015]|AETNA [101529]|2018||||2018|2018|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018|719.7|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018|719.7|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018|893|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018|553.78|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018|1191|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018|1191|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018|719.7|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018|825|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|992.06|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018|770.8|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018|2018|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018|719.7|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018|2018|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|Self-pay|Self-pay|2018||||2018|706.3|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|381.79|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018|567|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018|719.7|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018|719.7|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018|567|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018|719.7|2018|381.79
36045378|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY SPLENIC FLEXURE DX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018|1439.4|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AARP [1000]|AARP [100000]|2018||||2018|567|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018|949.74|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AETNA [1015]|AETNA [101529]|2018||||2018|2018|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018|940.33|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018|940.33|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018|893|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018|730.38|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018|1191|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018|1191|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018|940.33|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018|825|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018|1007.1|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018|2018|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018|940.33|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018|2018|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|Self-pay|Self-pay|2018||||2018|706.3|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|381.79|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018|567|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018|940.33|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018|940.33|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018|567|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018|940.33|2018|381.79
36045380|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/BIOPSY(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018|1880.67|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|AARP [1000]|AARP [100000]|2018||||2018|567|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018|949.74|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|AETNA [1015]|AETNA [101529]|2018||||2018|2018|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018|940.33|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018|940.33|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018|893|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018|730.38|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018|1191|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018|1191|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018|940.33|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018|825|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018|1007.1|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018|2018|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018|940.33|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018|2018|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|Self-pay|Self-pay|2018||||2018|706.3|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|381.79|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018|567|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018|940.33|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018|940.33|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018|567|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018|940.33|2018|381.79
36045381|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/DIRCT SUBMUC INJ(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018|1880.67|2018|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|AARP [1000]|AARP [100000]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|AETNA [1015]|AETNA [101529]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|Self-pay|Self-pay|2018||||2018|706.3|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|381.79|1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||1296.2|381.79
36045382|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/CONTROL BLEED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||1296.2|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AARP [1000]|AARP [100000]|2018||||2018|567|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018|949.74|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AETNA [1015]|AETNA [101529]|2018||||2018|2018|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018|940.33|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018|940.33|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018|893|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018|730.38|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018|1191|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018|1191|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018|940.33|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018|825|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018|1007.1|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018|2018|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018|940.33|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018|2018|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|Self-pay|Self-pay|2018||||2018|706.3|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|381.79|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018|567|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018|940.33|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018|940.33|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018|567|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018|940.33|2018|381.79
36045385|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/SNARE RMVL TUMORS POLYPS LESIONS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018|1880.67|2018|381.79
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|AARP [1000]|AARP [100000]|2018||||2018|567|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018|949.74|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|AETNA [1015]|AETNA [101529]|2018||||2018|2018|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018|940.33|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018|940.33|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018|1350|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018|730.38|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018|1682|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018|1800|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018|940.33|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018|1250|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018|1007.1|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018|2018|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018|940.33|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018|2018|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|Self-pay|Self-pay|2018||||2018|706.3|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|285.13|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018|567|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018|940.33|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018|940.33|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018|567|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018|940.33|2018|285.13
36045388|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ABLATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018|1880.67|2018|285.13
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|AARP [1000]|AARP [100000]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|AETNA [1015]|AETNA [101529]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|3054.24|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|Self-pay|Self-pay|2018||||2018|706.3|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|437.85|3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||3054.24|437.85
36045390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/RESECTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||3054.24|437.85
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|AARP [1000]|AARP [100000]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|AETNA [1015]|AETNA [101529]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|1296.2|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|Self-pay|Self-pay|2018||||2018|706.3|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|381.79|1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018||1296.2|381.79
36045391|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/US EXAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018||1296.2|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|AARP [1000]|AARP [100000]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|AETNA [1015]|AETNA [101529]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2450||||2450|726.43|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|BCBS [1155]|BCBS UTHCT [115568]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2450||||2450|726.43|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|CIGNA [1260]|CIGNA GWH [126023]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2450||||2450|1568|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2450||||2450|1296.2|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2450||||2450|726.43|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2450||||2450|726.43|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2450||||2450|726.43|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2450||||2450|1568|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2450||||2450|726.43|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|Self-pay|Self-pay|2450||||2450|857.5|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2450||||2450|726.43|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2450||||2450|381.79|1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2450||||2450||1568|381.79
36045392|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLONOSCOPY W/ENDOSCOPIC FNB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2450||||2450||1568|381.79
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AARP [1000]|AARP [100000]|21.7||||21.7|9.77|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.7||||21.7||14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AETNA [1015]|AETNA [101529]|21.7||||21.7|4.32|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.7||||21.7|6.43|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.7||||21.7||14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.7||||21.7||14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|21.7||||21.7|10.2|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.7||||21.7|0|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.7||||21.7|10.85|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.7||||21.7|13.67|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.7||||21.7|6.43|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.7||||21.7||14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|21.7||||21.7|11.94|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.7||||21.7|14.97|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.7||||21.7|0.2|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.7||||21.7||14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.7||||21.7|4.32|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.7||||21.7|6.43|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.7||||21.7||14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.7||||21.7|4.32|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.7||||21.7|6.43|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.7||||21.7|6.43|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.7||||21.7|14.97|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.7||||21.7|6.43|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|Self-pay|Self-pay|21.7||||21.7|7.59|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.7||||21.7|6.43|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.7||||21.7|6.43|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.7||||21.7|9.77|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.7||||21.7||14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.7||||21.7||14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.7||||21.7|9.77|14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.7||||21.7||14.97|0.2
36046|ERX|0258 - PHARMACY-IV SOLUTIONS|POTASSIUM CHLORIDE 20 MEQ/L IN 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLN|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.7||||21.7||14.97|0.2
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|AARP [1000]|AARP [100000]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|AETNA [1015]|AETNA [101529]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4093||||4093|1213.57|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|BCBS [1155]|BCBS UTHCT [115568]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4093||||4093|1213.57|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|CIGNA [1260]|CIGNA GWH [126023]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4093||||4093|2619.52|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4093||||4093|1296.2|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4093||||4093|1213.57|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4093||||4093|1213.57|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4093||||4093|1213.57|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4093||||4093|2619.52|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4093||||4093|1213.57|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|Self-pay|Self-pay|4093||||4093|1432.55|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4093||||4093|1213.57|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4093||||4093|437.85|2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4093||||4093||2619.52|437.85
36046040|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D ISCHIO/PERIRECTAL ABSCESS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4093||||4093||2619.52|437.85
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|AARP [1000]|AARP [100000]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|AETNA [1015]|AETNA [101529]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3480||||3480|1031.82|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|BCBS [1155]|BCBS UTHCT [115568]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3480||||3480|1031.82|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|CIGNA [1260]|CIGNA GWH [126023]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3480||||3480|2227.2|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3480||||3480|992.06|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3480||||3480|1031.82|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3480||||3480|1031.82|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3480||||3480|1031.82|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3480||||3480|2227.2|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3480||||3480|1031.82|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|Self-pay|Self-pay|3480||||3480|1218|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3480||||3480|1031.82|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3480||||3480|285.13|2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3480||||3480||2227.2|285.13
36046050|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERIANAL ABSCESS SUPERFIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3480||||3480||2227.2|285.13
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|AARP [1000]|AARP [100000]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|AETNA [1015]|AETNA [101529]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|477||||477|141.43|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|BCBS [1155]|BCBS UTHCT [115568]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|477||||477|141.43|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|CIGNA [1260]|CIGNA GWH [126023]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|477||||477|305.28|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|477||||477|332.68|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|477||||477|141.43|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|477||||477|141.43|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|477||||477|141.43|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|477||||477|305.28|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|477||||477|141.43|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|Self-pay|Self-pay|477||||477|166.95|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|477||||477|141.43|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|477||||477|285.13|332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|477||||477||332.68|141.43
36046083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INCISION EXTERNAL HEMORRHOID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|477||||477||332.68|141.43
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|AARP [1000]|AARP [100000]|2065||||2065|361|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2065||||2065|726.9|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|AETNA [1015]|AETNA [101529]|2065||||2065|2065|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2065||||2065|612.27|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2065||||2065|719.7|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2065||||2065|719.7|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|BCBS [1155]|BCBS UTHCT [115568]|2065||||2065|1350|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2065||||2065|140.4|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2065||||2065|1682|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2065||||2065|1800|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2065||||2065|612.27|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2065||||2065|719.7|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|CIGNA [1260]|CIGNA GWH [126023]|2065||||2065|575|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2065||||2065|1321.6|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2065||||2065|992.06|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2065||||2065|770.8|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2065||||2065|2065|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2065||||2065|612.27|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2065||||2065|719.7|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2065||||2065|2065|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2065||||2065|612.27|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2065||||2065|612.27|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2065||||2065|1321.6|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2065||||2065|612.27|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|Self-pay|Self-pay|2065||||2065|722.75|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2065||||2065|612.27|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2065||||2065|285.13|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2065||||2065|361|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2065||||2065|719.7|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2065||||2065|719.7|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2065||||2065|361|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2065||||2065|719.7|2065|140.4
36046221|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BAND LIGATION OF INTERNAL HEMORRHOID(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2065||||2065|1439.4|2065|140.4
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|AARP [1000]|AARP [100000]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|AETNA [1015]|AETNA [101529]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3899||||3899|1156.05|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|BCBS [1155]|BCBS UTHCT [115568]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3899||||3899|1156.05|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|CIGNA [1260]|CIGNA GWH [126023]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3899||||3899|2495.36|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3899||||3899|1296.2|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3899||||3899|1156.05|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3899||||3899|1156.05|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3899||||3899|1156.05|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3899||||3899|2495.36|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3899||||3899|1156.05|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|Self-pay|Self-pay|3899||||3899|1364.65|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3899||||3899|1156.05|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3899||||3899|381.79|2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3899||||3899||2495.36|381.79
36046320|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXC EXT THROMBOSED HEMORRHOID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3899||||3899||2495.36|381.79
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|AARP [1000]|AARP [100000]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|AETNA [1015]|AETNA [101529]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|268||||268|79.46|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|BCBS [1155]|BCBS UTHCT [115568]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|268||||268|79.46|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|CIGNA [1260]|CIGNA GWH [126023]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|268||||268|171.52|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|268||||268|139.94|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|268||||268|79.46|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|268||||268|79.46|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|268||||268|79.46|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|268||||268|171.52|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|268||||268|79.46|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|Self-pay|Self-pay|268||||268|93.8|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|268||||268|79.46|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|268||||268|79.46|171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|268||||268||171.52|79.46
36046600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ANOSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|268||||268||171.52|79.46
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|AARP [1000]|AARP [100000]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|AETNA [1015]|AETNA [101529]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3154||||3154|935.16|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|BCBS [1155]|BCBS UTHCT [115568]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3154||||3154|935.16|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|CIGNA [1260]|CIGNA GWH [126023]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3154||||3154|2018.56|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3154||||3154|3054.24|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3154||||3154|935.16|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3154||||3154|935.16|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3154||||3154|935.16|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3154||||3154|2018.56|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3154||||3154|935.16|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|Self-pay|Self-pay|3154||||3154|1103.9|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3154||||3154|935.16|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3154||||3154|285.13|3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3154||||3154||3054.24|285.13
36046922|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EXCISION OF ANAL LESION(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3154||||3154||3054.24|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|AARP [1000]|AARP [100000]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|AETNA [1015]|AETNA [101529]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2525||||2525|748.66|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|BCBS [1155]|BCBS UTHCT [115568]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2525||||2525|748.66|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|CIGNA [1260]|CIGNA GWH [126023]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2525||||2525|1616|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2525||||2525|1758.75|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2525||||2525|748.66|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2525||||2525|748.66|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2525||||2525|748.66|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2525||||2525|1616|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2525||||2525|748.66|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|Self-pay|Self-pay|2525||||2525|883.75|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2525||||2525|748.66|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2525||||2525|285.13|1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2525||||2525||1758.75|285.13
36047000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY LIVER NEEDLE PERC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2525||||2525||1758.75|285.13
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AARP [1000]|AARP [100000]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AETNA [1015]|AETNA [101529]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7708||||7708|2285.42|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS [1155]|BCBS UTHCT [115568]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7708||||7708|2285.42|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|CIGNA [1260]|CIGNA GWH [126023]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7708||||7708|4933.12|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7708||||7708|3979.26|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7708||||7708|2285.42|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7708||||7708|2285.42|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|7708||||7708|2285.42|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7708||||7708|4933.12|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7708||||7708|2285.42|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|Self-pay|Self-pay|7708||||7708|2697.8|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7708||||7708|2285.42|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7708||||7708|2285.42|4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7708||||7708||4933.12|2285.42
36047490|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLECYSTOSTOMY PRQ W/IMAGING & CATHETER PLMT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|AARP [1000]|AARP [100000]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|AETNA [1015]|AETNA [101529]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7708||||7708|2285.42|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|BCBS [1155]|BCBS UTHCT [115568]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7708||||7708|2285.42|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|CIGNA [1260]|CIGNA GWH [126023]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|7708||||7708|4933.12|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7708||||7708|3979.26|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7708||||7708|2285.42|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7708||||7708|2285.42|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|7708||||7708|2285.42|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|7708||||7708|4933.12|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7708||||7708|2285.42|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|Self-pay|Self-pay|7708||||7708|2697.8|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7708||||7708|2285.42|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7708||||7708|2285.42|4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7708||||7708||4933.12|2285.42
36047531|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHOLANGIOGRAM EXISTING ACCESS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7708||||7708||4933.12|2285.42
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|AARP [1000]|AARP [100000]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|AETNA [1015]|AETNA [101529]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3329||||3329|987.05|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|BCBS [1155]|BCBS UTHCT [115568]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3329||||3329|987.05|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|CIGNA [1260]|CIGNA GWH [126023]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3329||||3329|2130.56|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3329||||3329|1758.75|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3329||||3329|987.05|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3329||||3329|987.05|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3329||||3329|987.05|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3329||||3329|2130.56|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3329||||3329|987.05|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|Self-pay|Self-pay|3329||||3329|1165.15|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3329||||3329|987.05|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3329||||3329|285.13|2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3329||||3329||2130.56|285.13
36048102|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY PANCREAS NEEDLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3329||||3329||2130.56|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|AARP [1000]|AARP [100000]|2725.25||||2725.25|567|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2725.25||||2725.25|741.5|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|AETNA [1015]|AETNA [101529]|2725.25||||2725.25|2200|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2725.25||||2725.25|808.04|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2725.25||||2725.25|734.16|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2725.25||||2725.25|734.16|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|2725.25||||2725.25|1350|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2725.25||||2725.25|579.92|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2725.25||||2725.25|1682|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2725.25||||2725.25|1800|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2725.25||||2725.25|808.04|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2725.25||||2725.25|734.16|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|2725.25||||2725.25|575|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2725.25||||2725.25|1744.16|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2725.25||||2725.25|1012|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2725.25||||2725.25|786.28|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2725.25||||2725.25|2200|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2725.25||||2725.25|808.04|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2725.25||||2725.25|734.16|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2725.25||||2725.25|2200|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2725.25||||2725.25|808.04|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2725.25||||2725.25|808.04|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2725.25||||2725.25|1744.16|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2725.25||||2725.25|808.04|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|Self-pay|Self-pay|2725.25||||2725.25|953.84|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2725.25||||2725.25|808.04|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2725.25||||2725.25|285.13|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2725.25||||2725.25|567|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2725.25||||2725.25|734.16|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2725.25||||2725.25|734.16|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2725.25||||2725.25|567|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2725.25||||2725.25|734.16|2200|285.13
36049082|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/O IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2725.25||||2725.25|1468.32|2200|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AARP [1000]|AARP [100000]|1884||||1884|567|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1884||||1884|741.5|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AETNA [1015]|AETNA [101529]|1884||||1884|1884|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1884||||1884|558.61|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1884||||1884|734.16|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1884||||1884|734.16|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS [1155]|BCBS UTHCT [115568]|1884||||1884|1350|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1884||||1884|579.92|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1884||||1884|1682|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1884||||1884|1800|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1884||||1884|558.61|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1884||||1884|734.16|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|CIGNA [1260]|CIGNA GWH [126023]|1884||||1884|575|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1884||||1884|1205.76|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1884||||1884|1012|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1884||||1884|786.28|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1884||||1884|1884|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1884||||1884|558.61|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1884||||1884|734.16|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1884||||1884|1884|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1884||||1884|558.61|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1884||||1884|558.61|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1884||||1884|1205.76|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1884||||1884|558.61|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|Self-pay|Self-pay|1884||||1884|659.4|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1884||||1884|558.61|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1884||||1884|285.13|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1884||||1884|567|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1884||||1884|734.16|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1884||||1884|734.16|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1884||||1884|567|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1884||||1884|734.16|1884|285.13
36049083|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ABD PARACENTESIS W/IMAGING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1884||||1884|1468.32|1884|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|AARP [1000]|AARP [100000]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|AETNA [1015]|AETNA [101529]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1744||||1744|517.1|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|BCBS [1155]|BCBS UTHCT [115568]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1744||||1744|517.1|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|CIGNA [1260]|CIGNA GWH [126023]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1744||||1744|1116.16|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1744||||1744|1012|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1744||||1744|517.1|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1744||||1744|517.1|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1744||||1744|517.1|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1744||||1744|1116.16|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1744||||1744|517.1|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|Self-pay|Self-pay|1744||||1744|610.4|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1744||||1744|517.1|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1744||||1744|285.13|1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1744||||1744||1116.16|285.13
36049084|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PERITONEAL LAVAGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1744||||1744||1116.16|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|AARP [1000]|AARP [100000]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|AETNA [1015]|AETNA [101529]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1671||||1671|495.45|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|BCBS [1155]|BCBS UTHCT [115568]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1671||||1671|495.45|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|CIGNA [1260]|CIGNA GWH [126023]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1671||||1671|1069.44|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1671||||1671|1758.75|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1671||||1671|495.45|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1671||||1671|495.45|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1671||||1671|495.45|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1671||||1671|1069.44|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1671||||1671|495.45|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|Self-pay|Self-pay|1671||||1671|584.85|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1671||||1671|495.45|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1671||||1671|285.13|1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1671||||1671||1758.75|285.13
36049180|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY ABDOM/RETROPERITONIAL MASS PERC NDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1671||||1671||1758.75|285.13
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AARP [1000]|AARP [100000]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AETNA [1015]|AETNA [101529]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1632||||1632|483.89|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS [1155]|BCBS UTHCT [115568]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1632||||1632|483.89|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|CIGNA [1260]|CIGNA GWH [126023]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1632||||1632|1044.48|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1632||||1632|1758.75|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1632||||1632|483.89|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1632||||1632|483.89|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1632||||1632|483.89|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1632||||1632|1044.48|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1632||||1632|483.89|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|Self-pay|Self-pay|1632||||1632|571.2|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1632||||1632|483.89|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1632||||1632|483.89|1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1632||||1632||1758.75|483.89
36049405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC IMAGE CATH FLUID COLXN VISC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1632||||1632||1758.75|483.89
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|AARP [1000]|AARP [100000]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|AETNA [1015]|AETNA [101529]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3329||||3329|987.05|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|BCBS [1155]|BCBS UTHCT [115568]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3329||||3329|987.05|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|CIGNA [1260]|CIGNA GWH [126023]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3329||||3329|2130.56|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3329||||3329|1758.75|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3329||||3329|987.05|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3329||||3329|987.05|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3329||||3329|987.05|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3329||||3329|2130.56|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3329||||3329|987.05|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|Self-pay|Self-pay|3329||||3329|1165.15|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3329||||3329|987.05|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3329||||3329|381.79|2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3329||||3329||2130.56|381.79
36049406|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH DRAIN PERITONEAL/RETROPER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3329||||3329||2130.56|381.79
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|AARP [1000]|AARP [100000]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|AETNA [1015]|AETNA [101529]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|86||||86|25.5|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|BCBS [1155]|BCBS UTHCT [115568]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|86||||86|0|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|86||||86|25.5|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|CIGNA [1260]|CIGNA GWH [126023]|86||||86|0|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|86||||86|55.04|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|86||||86|43|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|86||||86|25.5|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|86||||86|25.5|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|86||||86|25.5|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|86||||86|55.04|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|86||||86|25.5|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|Self-pay|Self-pay|86||||86|30.1|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|86||||86|25.5|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|86||||86|25.5|55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|86||||86||55.04|25.5
36049424|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST VIA CATH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|86||||86||55.04|25.5
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|AARP [1000]|AARP [100000]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|AETNA [1015]|AETNA [101529]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3594||||3594|1065.62|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|BCBS [1155]|BCBS UTHCT [115568]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3594||||3594|1065.62|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|CIGNA [1260]|CIGNA GWH [126023]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3594||||3594|2300.16|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3594||||3594|2031.28|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3594||||3594|1065.62|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3594||||3594|1065.62|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3594||||3594|1065.62|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3594||||3594|2300.16|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3594||||3594|1065.62|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|Self-pay|Self-pay|3594||||3594|1257.9|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3594||||3594|1065.62|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3594||||3594|381.79|2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3594||||3594||2300.16|381.79
36049440|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT GASTRO TUBE W/ FLUORO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3594||||3594||2300.16|381.79
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|AARP [1000]|AARP [100000]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|AETNA [1015]|AETNA [101529]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1884||||1884|558.61|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|BCBS [1155]|BCBS UTHCT [115568]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1884||||1884|558.61|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|CIGNA [1260]|CIGNA GWH [126023]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1884||||1884|1205.76|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1884||||1884|1012|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1884||||1884|558.61|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1884||||1884|558.61|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1884||||1884|558.61|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1884||||1884|1205.76|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1884||||1884|558.61|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|Self-pay|Self-pay|1884||||1884|659.4|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1884||||1884|558.61|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1884||||1884|285.13|1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1884||||1884||1205.76|285.13
36049451|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPLACE DUOD/JEJ TUBE PERC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1884||||1884||1205.76|285.13
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AARP [1000]|AARP [100000]|608||||608|119|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|608||||608|210.77|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AETNA [1015]|AETNA [101529]|608||||608|608|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|608||||608|180.27|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|608||||608|208.68|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|608||||608|208.68|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS [1155]|BCBS UTHCT [115568]|608||||608|1350|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|608||||608|181.2|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|608||||608|1682|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|608||||608|1800|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|608||||608|180.27|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|608||||608|208.68|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|CIGNA [1260]|CIGNA GWH [126023]|608||||608|150|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|608||||608|389.12|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|608||||608|287.66|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|608||||608|223.5|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|608||||608|608|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|608||||608|180.27|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|608||||608|208.68|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|608||||608|608|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|608||||608|180.27|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|608||||608|180.27|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|608||||608|389.12|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|608||||608|180.27|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|Self-pay|Self-pay|608||||608|212.8|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|608||||608|180.27|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|608||||608|180.27|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|608||||608|119|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|608||||608|208.68|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|608||||608|208.68|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|608||||608|119|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|608||||608|208.68|1800|119
36049465|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CONTRAST EXISTING TUBE GI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|608||||608|417.37|1800|119
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|AARP [1000]|AARP [100000]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|AETNA [1015]|AETNA [101529]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3329||||3329|987.05|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|BCBS [1155]|BCBS UTHCT [115568]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3329||||3329|987.05|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|CIGNA [1260]|CIGNA GWH [126023]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3329||||3329|2130.56|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3329||||3329|1758.75|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3329||||3329|987.05|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3329||||3329|987.05|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3329||||3329|987.05|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3329||||3329|2130.56|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3329||||3329|987.05|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|Self-pay|Self-pay|3329||||3329|1165.15|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3329||||3329|987.05|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3329||||3329|285.13|2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3329||||3329||2130.56|285.13
36050200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY RENAL TROCAR/NEEDLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3329||||3329||2130.56|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|AARP [1000]|AARP [100000]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|AETNA [1015]|AETNA [101529]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1299||||1299|385.15|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|BCBS [1155]|BCBS UTHCT [115568]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1299||||1299|385.15|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|CIGNA [1260]|CIGNA GWH [126023]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1299||||1299|831.36|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1299||||1299|777.46|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1299||||1299|385.15|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1299||||1299|385.15|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1299||||1299|385.15|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1299||||1299|831.36|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1299||||1299|385.15|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|Self-pay|Self-pay|1299||||1299|454.65|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1299||||1299|385.15|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1299||||1299|285.13|831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1299||||1299||831.36|285.13
36050390|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP/INJ RENAL CYST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1299||||1299||831.36|285.13
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|AARP [1000]|AARP [100000]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|AETNA [1015]|AETNA [101529]|1292||||1292|1292|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1292||||1292|383.08|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|BCBS [1155]|BCBS UTHCT [115568]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1292||||1292|0|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1292||||1292|383.08|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|CIGNA [1260]|CIGNA GWH [126023]|1292||||1292|0|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1292||||1292|826.88|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1292||||1292|646|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1292||||1292|1292|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1292||||1292|383.08|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1292||||1292|1292|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1292||||1292|383.08|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1292||||1292|383.08|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1292||||1292|826.88|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1292||||1292|383.08|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|Self-pay|Self-pay|1292||||1292|452.2|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1292||||1292|383.08|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1292||||1292|383.08|1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1292||||1292||1292|383.08
36051600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ CYSTOGRAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1292||||1292||1292|383.08
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|AARP [1000]|AARP [100000]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|AETNA [1015]|AETNA [101529]|194||||194|194|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|194||||194|57.52|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|BCBS [1155]|BCBS UTHCT [115568]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|194||||194|0|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|194||||194|57.52|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|CIGNA [1260]|CIGNA GWH [126023]|194||||194|0|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|194||||194|124.16|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|194||||194|97|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|194||||194|194|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|194||||194|57.52|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|194||||194|194|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|194||||194|57.52|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|194||||194|57.52|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|194||||194|124.16|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|194||||194|57.52|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|Self-pay|Self-pay|194||||194|67.9|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|194||||194|57.52|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|194||||194|57.52|194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|194||||194||194|57.52
36051610|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC URETHROCYSTOGRAM RETRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|194||||194||194|57.52
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|AARP [1000]|AARP [100000]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|AETNA [1015]|AETNA [101529]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|828.15||||828.15|245.55|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|BCBS [1155]|BCBS UTHCT [115568]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|828.15||||828.15|245.55|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|CIGNA [1260]|CIGNA GWH [126023]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|828.15||||828.15|530.02|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|828.15||||828.15|332.68|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|828.15||||828.15|245.55|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|828.15||||828.15|245.55|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|828.15||||828.15|245.55|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|828.15||||828.15|530.02|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|828.15||||828.15|245.55|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|Self-pay|Self-pay|828.15||||828.15|289.85|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|828.15||||828.15|245.55|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|828.15||||828.15|285.13|530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|828.15||||828.15||530.02|245.55
36051700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER IRRIGATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|828.15||||828.15||530.02|245.55
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|AARP [1000]|AARP [100000]|381.05||||381.05|119|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|381.05||||381.05|102.53|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|AETNA [1015]|AETNA [101529]|381.05||||381.05|381.05|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|381.05||||381.05|112.98|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|381.05||||381.05|101.52|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|381.05||||381.05|101.52|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|BCBS [1155]|BCBS UTHCT [115568]|381.05||||381.05|1350|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|381.05||||381.05|81.93|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|381.05||||381.05|1682|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|381.05||||381.05|1800|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|381.05||||381.05|112.98|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|381.05||||381.05|101.52|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|CIGNA [1260]|CIGNA GWH [126023]|381.05||||381.05|150|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|381.05||||381.05|243.87|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|381.05||||381.05|139.94|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|381.05||||381.05|108.73|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|381.05||||381.05|381.05|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|381.05||||381.05|112.98|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|381.05||||381.05|101.52|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|381.05||||381.05|381.05|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|381.05||||381.05|112.98|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|381.05||||381.05|112.98|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|381.05||||381.05|243.87|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|381.05||||381.05|112.98|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|Self-pay|Self-pay|381.05||||381.05|133.37|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|381.05||||381.05|112.98|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|381.05||||381.05|112.98|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|381.05||||381.05|119|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|381.05||||381.05|101.52|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|381.05||||381.05|101.52|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|381.05||||381.05|119|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|381.05||||381.05|101.52|1800|81.93
36051701|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH STRAIGHT BLADDER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|381.05||||381.05|203.04|1800|81.93
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|AARP [1000]|AARP [100000]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|AETNA [1015]|AETNA [101529]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|232||||232|68.79|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|BCBS [1155]|BCBS UTHCT [115568]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|232||||232|68.79|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|CIGNA [1260]|CIGNA GWH [126023]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|232||||232|148.48|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|232||||232|139.94|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|232||||232|68.79|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|232||||232|68.79|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|232||||232|68.79|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|232||||232|148.48|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|232||||232|68.79|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|Self-pay|Self-pay|232||||232|81.2|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|232||||232|68.79|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|232||||232|68.79|148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|232||||232||148.48|68.79
36051702|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDER SMPL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|232||||232||148.48|68.79
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|AARP [1000]|AARP [100000]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|AETNA [1015]|AETNA [101529]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|583||||583|172.86|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|BCBS [1155]|BCBS UTHCT [115568]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|583||||583|172.86|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|CIGNA [1260]|CIGNA GWH [126023]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|583||||583|373.12|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|583||||583|174.44|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|583||||583|172.86|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|583||||583|172.86|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|583||||583|172.86|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|583||||583|373.12|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|583||||583|172.86|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|Self-pay|Self-pay|583||||583|204.05|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|583||||583|172.86|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|583||||583|285.13|373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|583||||583||373.12|172.86
36051703|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INSERT CATH FOLEY BLADDR CMPLX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|AARP [1000]|AARP [100000]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|AETNA [1015]|AETNA [101529]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|583||||583|172.86|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|BCBS [1155]|BCBS UTHCT [115568]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|583||||583|172.86|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|CIGNA [1260]|CIGNA GWH [126023]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|583||||583|373.12|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|583||||583|332.68|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|583||||583|172.86|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|583||||583|172.86|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|583||||583|172.86|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|583||||583|373.12|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|583||||583|172.86|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|Self-pay|Self-pay|583||||583|204.05|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|583||||583|172.86|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|583||||583|285.13|373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|583||||583||373.12|172.86
36051705|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SUPRAPUBIC CATHETER CHANGE SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|583||||583||373.12|172.86
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|AARP [1000]|AARP [100000]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|AETNA [1015]|AETNA [101529]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|828.51||||828.51|245.65|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|BCBS [1155]|BCBS UTHCT [115568]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|828.51||||828.51|245.65|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|CIGNA [1260]|CIGNA GWH [126023]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|828.51||||828.51|530.25|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|828.51||||828.51|332.68|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|828.51||||828.51|245.65|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|828.51||||828.51|245.65|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|828.51||||828.51|245.65|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|828.51||||828.51|530.25|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|828.51||||828.51|245.65|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|Self-pay|Self-pay|828.51||||828.51|289.98|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|828.51||||828.51|245.65|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|828.51||||828.51|285.13|530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|828.51||||828.51||530.25|245.65
36051720|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLADDER INSTILLATION ANTICARCINOGENIC AGENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|828.51||||828.51||530.25|245.65
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|AARP [1000]|AARP [100000]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|AETNA [1015]|AETNA [101529]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|196||||196|58.11|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|BCBS [1155]|BCBS UTHCT [115568]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|196||||196|58.11|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|CIGNA [1260]|CIGNA GWH [126023]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|196||||196|125.44|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|196||||196|332.68|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|196||||196|58.11|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|196||||196|58.11|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|196||||196|58.11|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|196||||196|125.44|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|196||||196|58.11|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|Self-pay|Self-pay|196||||196|68.6|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|196||||196|58.11|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|196||||196|196|332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|196||||196||332.68|58.11
36051725|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE CYSTOMETROGRAM (CMG)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|196||||196||332.68|58.11
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|AARP [1000]|AARP [100000]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|AETNA [1015]|AETNA [101529]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|635||||635|188.28|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|BCBS [1155]|BCBS UTHCT [115568]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|635||||635|188.28|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|CIGNA [1260]|CIGNA GWH [126023]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|635||||635|406.4|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|635||||635|332.68|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|635||||635|188.28|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|635||||635|188.28|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|635||||635|188.28|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|635||||635|406.4|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|635||||635|188.28|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|Self-pay|Self-pay|635||||635|222.25|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|635||||635|188.28|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|635||||635|285.13|406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|635||||635||406.4|188.28
36051726|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|635||||635||406.4|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|AARP [1000]|AARP [100000]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|AETNA [1015]|AETNA [101529]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|635||||635|188.28|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|BCBS [1155]|BCBS UTHCT [115568]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|635||||635|188.28|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|CIGNA [1260]|CIGNA GWH [126023]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|635||||635|406.4|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|635||||635|718.46|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|635||||635|188.28|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|635||||635|188.28|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|635||||635|188.28|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|635||||635|406.4|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|635||||635|188.28|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|Self-pay|Self-pay|635||||635|222.25|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|635||||635|188.28|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|635||||635|285.13|718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|635||||635||718.46|188.28
36051728|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX CYSTOMETROGRAM W/VOIDING PRESSURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|AARP [1000]|AARP [100000]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|AETNA [1015]|AETNA [101529]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|635||||635|188.28|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|BCBS [1155]|BCBS UTHCT [115568]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|635||||635|188.28|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|CIGNA [1260]|CIGNA GWH [126023]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|635||||635|406.4|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|635||||635|718.46|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|635||||635|188.28|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|635||||635|188.28|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|635||||635|188.28|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|635||||635|406.4|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|635||||635|188.28|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|Self-pay|Self-pay|635||||635|222.25|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|635||||635|188.28|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|635||||635|285.13|718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|635||||635||718.46|188.28
36051729|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLX CYSTOMETRO W/VOIDING&URETH PRESSURE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|635||||635||718.46|188.28
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|AARP [1000]|AARP [100000]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|AETNA [1015]|AETNA [101529]|269||||269|269|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|269||||269|79.76|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|BCBS [1155]|BCBS UTHCT [115568]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|269||||269|79.76|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|CIGNA [1260]|CIGNA GWH [126023]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|269||||269|172.16|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|269||||269|139.94|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|269||||269|269|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|269||||269|79.76|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|269||||269|269|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|269||||269|79.76|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|269||||269|79.76|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|269||||269|172.16|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|269||||269|79.76|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|Self-pay|Self-pay|269||||269|94.15|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|269||||269|79.76|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|269||||269|79.76|269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|269||||269||269|79.76
36051736|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC SIMPLE UROFLOMETRY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|269||||269||269|79.76
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|AARP [1000]|AARP [100000]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|AETNA [1015]|AETNA [101529]|224||||224|224|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|224||||224|66.42|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|BCBS [1155]|BCBS UTHCT [115568]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|224||||224|66.42|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|CIGNA [1260]|CIGNA GWH [126023]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|224||||224|143.36|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|224||||224|174.44|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|224||||224|224|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|224||||224|66.42|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|224||||224|224|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|224||||224|66.42|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|224||||224|66.42|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|224||||224|143.36|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|224||||224|66.42|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|Self-pay|Self-pay|224||||224|78.4|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|224||||224|66.42|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|224||||224|66.42|224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|224||||224||224|66.42
36051741|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COMPLEX UROFLOMETRY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|224||||224||224|66.42
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|AARP [1000]|AARP [100000]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|AETNA [1015]|AETNA [101529]|237||||237|237|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237||||237|70.27|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|BCBS [1155]|BCBS UTHCT [115568]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237||||237|70.27|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|CIGNA [1260]|CIGNA GWH [126023]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|237||||237|151.68|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|237||||237|174.44|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237||||237|237|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237||||237|70.27|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237||||237|237|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237||||237|70.27|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|237||||237|70.27|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|237||||237|151.68|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237||||237|70.27|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|Self-pay|Self-pay|237||||237|82.95|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|237||||237|70.27|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237||||237|237|237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237||||237||237|70.27
36051784|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC EMG URINE/ANAL SPHINCTER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237||||237||237|70.27
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|AARP [1000]|AARP [100000]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|AETNA [1015]|AETNA [101529]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|418||||418|123.94|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|BCBS [1155]|BCBS UTHCT [115568]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|418||||418|0|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|418||||418|123.94|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|CIGNA [1260]|CIGNA GWH [126023]|418||||418|0|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|418||||418|267.52|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|418||||418|209|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|418||||418|123.94|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|418||||418|123.94|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|418||||418|123.94|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|418||||418|267.52|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|418||||418|123.94|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|Self-pay|Self-pay|418||||418|146.3|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|418||||418|123.94|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|418||||418|123.94|267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|418||||418||267.52|123.94
36051797|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VOID PRESSURE STUDIES INTRAABDOMINAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|418||||418||267.52|123.94
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AARP [1000]|AARP [100000]|124||||124|124|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|124||||124|50.97|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AETNA [1015]|AETNA [101529]|124||||124|54.68|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|124||||124|36.77|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|124||||124|50.47|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|124||||124|50.47|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS [1155]|BCBS UTHCT [115568]|124||||124|58.28|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|124||||124|89.28|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|124||||124|62|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|124||||124|78.12|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|124||||124|36.77|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|124||||124|50.47|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|CIGNA [1260]|CIGNA GWH [126023]|124||||124|124|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|124||||124|85.56|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|124||||124|69.58|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|124||||124|54.05|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|124||||124|54.68|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|124||||124|36.77|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|124||||124|50.47|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|124||||124|54.68|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|124||||124|36.77|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|124||||124|36.77|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|124||||124|85.56|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|124||||124|36.77|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|Self-pay|Self-pay|124||||124|43.4|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|124||||124|36.77|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|124||||124|36.77|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|124||||124|124|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|124||||124|50.47|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|124||||124|50.47|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|124||||124|124|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|124||||124|50.47|124|36.77
36051798|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC POST VOID BLADDER SCAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|124||||124|100.94|124|36.77
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|AARP [1000]|AARP [100000]|3763||||3763|361|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3763||||3763|526.42|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|AETNA [1015]|AETNA [101529]|3763||||3763|2200|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3763||||3763|1115.73|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3763||||3763|521.21|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3763||||3763|521.21|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|BCBS [1155]|BCBS UTHCT [115568]|3763||||3763|667|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3763||||3763|441.16|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3763||||3763|889|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3763||||3763|889|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3763||||3763|1115.73|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3763||||3763|521.21|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|CIGNA [1260]|CIGNA GWH [126023]|3763||||3763|575|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3763||||3763|2408.32|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3763||||3763|718.46|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3763||||3763|558.22|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3763||||3763|2200|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3763||||3763|1115.73|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3763||||3763|521.21|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3763||||3763|2200|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3763||||3763|1115.73|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3763||||3763|1115.73|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3763||||3763|2408.32|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3763||||3763|1115.73|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|Self-pay|Self-pay|3763||||3763|1317.05|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3763||||3763|1115.73|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3763||||3763|285.13|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3763||||3763|361|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3763||||3763|521.21|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3763||||3763|521.21|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3763||||3763|361|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3763||||3763|521.21|2408.32|285.13
36052000|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTOURETHROSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3763||||3763|1042.42|2408.32|285.13
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|AARP [1000]|AARP [100000]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|AETNA [1015]|AETNA [101529]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5429||||5429|1609.7|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|BCBS [1155]|BCBS UTHCT [115568]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5429||||5429|1609.7|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|CIGNA [1260]|CIGNA GWH [126023]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5429||||5429|3474.56|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5429||||5429|2241.24|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5429||||5429|1609.7|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5429||||5429|1609.7|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5429||||5429|1609.7|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5429||||5429|3474.56|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5429||||5429|1609.7|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|Self-pay|Self-pay|5429||||5429|1900.15|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5429||||5429|1609.7|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5429||||5429|381.79|3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5429||||5429||3474.56|381.79
36052281|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILATION OF URETHRAL STENOSIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5429||||5429||3474.56|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|AARP [1000]|AARP [100000]|4395||||4395|567|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4395||||4395|1642.17|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|AETNA [1015]|AETNA [101529]|4395||||4395|2200|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4395||||4395|1303.12|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4395||||4395|1625.92|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4395||||4395|1625.92|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|BCBS [1155]|BCBS UTHCT [115568]|4395||||4395|893|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4395||||4395|1322.63|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4395||||4395|1191|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4395||||4395|1191|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4395||||4395|1303.12|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4395||||4395|1625.92|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|CIGNA [1260]|CIGNA GWH [126023]|4395||||4395|825|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4395||||4395|2812.8|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4395||||4395|2241.24|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4395||||4395|1741.36|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4395||||4395|2200|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4395||||4395|1303.12|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4395||||4395|1625.92|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4395||||4395|2200|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4395||||4395|1303.12|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4395||||4395|1303.12|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4395||||4395|2812.8|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4395||||4395|1303.12|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|Self-pay|Self-pay|4395||||4395|1538.25|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4395||||4395|1303.12|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4395||||4395|381.79|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4395||||4395|567|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4395||||4395|1625.92|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4395||||4395|1625.92|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4395||||4395|567|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4395||||4395|1625.92|3251.83|381.79
36052310|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CYSTO W/SIMPLE REMOVAL STONE & STENT & LITHO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4395||||4395|3251.83|3251.83|381.79
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|AARP [1000]|AARP [100000]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|AETNA [1015]|AETNA [101529]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1342||||1342|397.9|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|BCBS [1155]|BCBS UTHCT [115568]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1342||||1342|397.9|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|CIGNA [1260]|CIGNA GWH [126023]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1342||||1342|858.88|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1342||||1342|2241.24|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1342||||1342|397.9|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1342||||1342|397.9|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1342||||1342|397.9|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1342||||1342|858.88|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1342||||1342|397.9|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|Self-pay|Self-pay|1342||||1342|469.7|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1342||||1342|397.9|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1342||||1342|285.13|2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1342||||1342||2241.24|285.13
36053020|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC MEATOTOMY CUTTING MEATUS SPX EXCEPT INFANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1342||||1342||2241.24|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|AARP [1000]|AARP [100000]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|AETNA [1015]|AETNA [101529]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2887||||2887|856|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|BCBS [1155]|BCBS UTHCT [115568]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2887||||2887|856|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|CIGNA [1260]|CIGNA GWH [126023]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2887||||2887|1847.68|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2887||||2887|332.68|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2887||||2887|856|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2887||||2887|856|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2887||||2887|856|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2887||||2887|1847.68|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2887||||2887|856|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|Self-pay|Self-pay|2887||||2887|1010.45|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2887||||2887|856|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2887||||2887|285.13|1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2887||||2887||1847.68|285.13
36053600|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE INITIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2887||||2887||1847.68|285.13
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|AARP [1000]|AARP [100000]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|AETNA [1015]|AETNA [101529]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|327||||327|96.96|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|BCBS [1155]|BCBS UTHCT [115568]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|327||||327|96.96|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|CIGNA [1260]|CIGNA GWH [126023]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|327||||327|209.28|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|327||||327|139.94|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|327||||327|96.96|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|327||||327|96.96|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|327||||327|96.96|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|327||||327|209.28|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|327||||327|96.96|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|Self-pay|Self-pay|327||||327|114.45|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|327||||327|96.96|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|327||||327|285.13|285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|327||||327||285.13|96.96
36053601|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETH STRICTURE SOUND/DILATOR MALE SUBSEQ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|327||||327||285.13|96.96
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|AARP [1000]|AARP [100000]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|AETNA [1015]|AETNA [101529]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2590||||2590|767.94|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|BCBS [1155]|BCBS UTHCT [115568]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2590||||2590|767.94|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|CIGNA [1260]|CIGNA GWH [126023]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2590||||2590|1657.6|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2590||||2590|718.46|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2590||||2590|767.94|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2590||||2590|767.94|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2590||||2590|767.94|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2590||||2590|1657.6|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2590||||2590|767.94|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|Self-pay|Self-pay|2590||||2590|906.5|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2590||||2590|767.94|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2590||||2590|285.13|1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2590||||2590||1657.6|285.13
36053620|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT URETHRAL STRIX FILIFORM & FOLLWR MALE 1ST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2590||||2590||1657.6|285.13
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|AARP [1000]|AARP [100000]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|AETNA [1015]|AETNA [101529]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|415||||415|123.05|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|BCBS [1155]|BCBS UTHCT [115568]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|415||||415|123.05|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|CIGNA [1260]|CIGNA GWH [126023]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|415||||415|265.6|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|415||||415|174.44|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|415||||415|123.05|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|415||||415|123.05|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|415||||415|123.05|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|415||||415|265.6|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|415||||415|123.05|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|Self-pay|Self-pay|415||||415|145.25|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|415||||415|123.05|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|415||||415|285.13|285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|415||||415||285.13|123.05
36053660|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DILAT FEMALE URETHRA W/SUPPOSITORY&/INSTLJ INI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|415||||415||285.13|123.05
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|AARP [1000]|AARP [100000]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|AETNA [1015]|AETNA [101529]|129||||129|129|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|129||||129|38.25|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|BCBS [1155]|BCBS UTHCT [115568]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|129||||129|38.25|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|CIGNA [1260]|CIGNA GWH [126023]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|129||||129|82.56|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|129||||129|224.44|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|129||||129|129|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|129||||129|38.25|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|129||||129|129|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|129||||129|38.25|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|129||||129|38.25|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|129||||129|82.56|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|129||||129|38.25|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|Self-pay|Self-pay|129||||129|45.15|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|129||||129|38.25|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|129||||129|38.25|224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|129||||129||224.44|38.25
36054056|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CRYOSURGERY PENIS LESION(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|129||||129||224.44|38.25
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|AARP [1000]|AARP [100000]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|AETNA [1015]|AETNA [101529]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5909||||5909|1752.02|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|BCBS [1155]|BCBS UTHCT [115568]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5909||||5909|1752.02|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|CIGNA [1260]|CIGNA GWH [126023]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5909||||5909|3781.76|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5909||||5909|2241.24|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5909||||5909|1752.02|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5909||||5909|1752.02|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5909||||5909|1752.02|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5909||||5909|3781.76|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5909||||5909|1752.02|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|Self-pay|Self-pay|5909||||5909|2068.15|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5909||||5909|1752.02|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5909||||5909|381.79|3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5909||||5909||3781.76|381.79
36054161|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CIRCUMCISION AGE >28 DAYS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5909||||5909||3781.76|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|AARP [1000]|AARP [100000]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|AETNA [1015]|AETNA [101529]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2982||||2982|884.16|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|BCBS [1155]|BCBS UTHCT [115568]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2982||||2982|884.16|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|CIGNA [1260]|CIGNA GWH [126023]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2982||||2982|1908.48|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2982||||2982|2241.24|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2982||||2982|884.16|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2982||||2982|884.16|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2982||||2982|884.16|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2982||||2982|1908.48|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2982||||2982|884.16|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|Self-pay|Self-pay|2982||||2982|1043.7|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2982||||2982|884.16|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2982||||2982|381.79|2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2982||||2982||2241.24|381.79
36054163|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REPAIR INCOMPLETE CIRCUMCISION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2982||||2982||2241.24|381.79
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|AARP [1000]|AARP [100000]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|AETNA [1015]|AETNA [101529]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|324||||324|96.07|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|BCBS [1155]|BCBS UTHCT [115568]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|324||||324|96.07|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|CIGNA [1260]|CIGNA GWH [126023]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|324||||324|207.36|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|324||||324|332.68|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|324||||324|96.07|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|324||||324|96.07|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|324||||324|96.07|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|324||||324|207.36|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|324||||324|96.07|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|Self-pay|Self-pay|324||||324|113.4|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|324||||324|96.07|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|324||||324|285.13|332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|324||||324||332.68|96.07
36054450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FORESKIN MANIPULATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|324||||324||332.68|96.07
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|AARP [1000]|AARP [100000]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|AETNA [1015]|AETNA [101529]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6613||||6613|1960.75|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|BCBS [1155]|BCBS UTHCT [115568]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6613||||6613|1960.75|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|CIGNA [1260]|CIGNA GWH [126023]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6613||||6613|4232.32|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6613||||6613|2241.24|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6613||||6613|1960.75|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6613||||6613|1960.75|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6613||||6613|1960.75|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6613||||6613|4232.32|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6613||||6613|1960.75|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|Self-pay|Self-pay|6613||||6613|2314.55|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6613||||6613|1960.75|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6613||||6613|381.79|4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6613||||6613||4232.32|381.79
36054700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D EPIDIDYMIS/TESTIS/SCROTAL SPACE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6613||||6613||4232.32|381.79
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|AARP [1000]|AARP [100000]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|AETNA [1015]|AETNA [101529]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2332||||2332|691.44|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|BCBS [1155]|BCBS UTHCT [115568]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2332||||2332|691.44|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|CIGNA [1260]|CIGNA GWH [126023]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2332||||2332|1492.48|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2332||||2332|1758.75|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2332||||2332|691.44|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2332||||2332|691.44|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2332||||2332|691.44|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2332||||2332|1492.48|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2332||||2332|691.44|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|Self-pay|Self-pay|2332||||2332|816.2|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2332||||2332|691.44|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2332||||2332|285.13|1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2332||||2332||1758.75|285.13
36055100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAINAGE SCROTAL WALL ABSCESS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2332||||2332||1758.75|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|AARP [1000]|AARP [100000]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|AETNA [1015]|AETNA [101529]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4640||||4640|1375.76|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|BCBS [1155]|BCBS UTHCT [115568]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4640||||4640|1375.76|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|CIGNA [1260]|CIGNA GWH [126023]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4640||||4640|2969.6|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4640||||4640|2241.24|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4640||||4640|1375.76|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4640||||4640|1375.76|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4640||||4640|1375.76|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4640||||4640|2969.6|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4640||||4640|1375.76|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|Self-pay|Self-pay|4640||||4640|1624|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4640||||4640|1375.76|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4640||||4640|285.13|2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4640||||4640||2969.6|285.13
36055250|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC VASECTOMY UNI/BILAT INCLUDES POSTOP SEMEN EXAM(S)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4640||||4640||2969.6|285.13
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|AARP [1000]|AARP [100000]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|AETNA [1015]|AETNA [101529]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4150||||4150|1230.48|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|BCBS [1155]|BCBS UTHCT [115568]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4150||||4150|1230.48|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|CIGNA [1260]|CIGNA GWH [126023]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4150||||4150|2656|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4150||||4150|2241.24|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4150||||4150|1230.48|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4150||||4150|1230.48|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4150||||4150|1230.48|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4150||||4150|2656|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4150||||4150|1230.48|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|Self-pay|Self-pay|4150||||4150|1452.5|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4150||||4150|1230.48|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4150||||4150|381.79|2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4150||||4150||2656|381.79
36055700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) PROSTATE NDL/PUNCH ANY APPROACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4150||||4150||2656|381.79
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|AARP [1000]|AARP [100000]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|AETNA [1015]|AETNA [101529]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11437||||11437|3391.07|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|BCBS [1155]|BCBS UTHCT [115568]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11437||||11437|3391.07|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|CIGNA [1260]|CIGNA GWH [126023]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|11437||||11437|7319.68|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11437||||11437|5517.38|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11437||||11437|3391.07|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11437||||11437|3391.07|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|11437||||11437|3391.07|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|11437||||11437|7319.68|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11437||||11437|3391.07|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|Self-pay|Self-pay|11437||||11437|4002.95|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11437||||11437|3391.07|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11437||||11437|1111.54|7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11437||||11437||7319.68|1111.54
36055874|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC TRANSPERINEAL PLMT BIODEGRADABLE MATRL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11437||||11437||7319.68|1111.54
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|AARP [1000]|AARP [100000]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|AETNA [1015]|AETNA [101529]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|983||||983|291.46|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|BCBS [1155]|BCBS UTHCT [115568]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|983||||983|291.46|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|CIGNA [1260]|CIGNA GWH [126023]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|983||||983|629.12|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|983||||983|351.85|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|983||||983|291.46|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|983||||983|291.46|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|983||||983|291.46|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|983||||983|629.12|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|983||||983|291.46|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|Self-pay|Self-pay|983||||983|344.05|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|983||||983|291.46|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|983||||983|381.79|629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|983||||983||629.12|291.46
36056405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D PERINEAL ABSCESS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|983||||983||629.12|291.46
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|AARP [1000]|AARP [100000]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|AETNA [1015]|AETNA [101529]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|499||||499|147.95|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|BCBS [1155]|BCBS UTHCT [115568]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|499||||499|147.95|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|CIGNA [1260]|CIGNA GWH [126023]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|499||||499|319.36|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|499||||499|212.9|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|499||||499|147.95|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|499||||499|147.95|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|499||||499|147.95|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|499||||499|319.36|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|499||||499|147.95|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|Self-pay|Self-pay|499||||499|174.65|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|499||||499|147.95|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|499||||499|285.13|319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|499||||499||319.36|147.95
36056420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC I&D BARTHOLIN GLAND ABSCESS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|499||||499||319.36|147.95
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|AARP [1000]|AARP [100000]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|AETNA [1015]|AETNA [101529]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|705||||705|209.03|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|BCBS [1155]|BCBS UTHCT [115568]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|705||||705|209.03|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|CIGNA [1260]|CIGNA GWH [126023]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|705||||705|451.2|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|705||||705|791.76|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|705||||705|209.03|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|705||||705|209.03|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|705||||705|209.03|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|705||||705|451.2|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|705||||705|209.03|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|Self-pay|Self-pay|705||||705|246.75|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|705||||705|209.03|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|705||||705|285.13|791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|705||||705||791.76|209.03
36056605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF VULVA/PERINEUM 1 LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|705||||705||791.76|209.03
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|AARP [1000]|AARP [100000]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|AETNA [1015]|AETNA [101529]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3151||||3151|934.27|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|BCBS [1155]|BCBS UTHCT [115568]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3151||||3151|934.27|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|CIGNA [1260]|CIGNA GWH [126023]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3151||||3151|2016.64|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3151||||3151|3279.01|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3151||||3151|934.27|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3151||||3151|934.27|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3151||||3151|934.27|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3151||||3151|2016.64|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3151||||3151|934.27|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|Self-pay|Self-pay|3151||||3151|1102.85|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3151||||3151|934.27|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3151||||3151|285.13|3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3151||||3151||3279.01|285.13
36057061|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT VAGINAL LESION(S) SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3151||||3151||3279.01|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|AARP [1000]|AARP [100000]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|AETNA [1015]|AETNA [101529]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1726||||1726|511.76|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|BCBS [1155]|BCBS UTHCT [115568]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1726||||1726|511.76|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|CIGNA [1260]|CIGNA GWH [126023]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1726||||1726|1104.64|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1726||||1726|791.76|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1726||||1726|511.76|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1726||||1726|511.76|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1726||||1726|511.76|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1726||||1726|1104.64|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1726||||1726|511.76|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|Self-pay|Self-pay|1726||||1726|604.1|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1726||||1726|511.76|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1726||||1726|285.13|1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1726||||1726||1104.64|285.13
36057100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY VAGINA MUCOSA SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1726||||1726||1104.64|285.13
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|AARP [1000]|AARP [100000]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|AETNA [1015]|AETNA [101529]|324||||324|324|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|324||||324|96.07|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|BCBS [1155]|BCBS UTHCT [115568]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|324||||324|96.07|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|CIGNA [1260]|CIGNA GWH [126023]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|324||||324|207.36|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|324||||324|212.9|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|324||||324|324|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|324||||324|96.07|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|324||||324|324|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|324||||324|96.07|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|324||||324|96.07|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|324||||324|207.36|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|324||||324|96.07|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|Self-pay|Self-pay|324||||324|113.4|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|324||||324|96.07|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|324||||324|285.13|324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|324||||324||324|96.07
36057160|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC FITTING AND INSERT OF PESSARY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|324||||324||324|96.07
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|AARP [1000]|AARP [100000]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|AETNA [1015]|AETNA [101529]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|426||||426|126.31|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|BCBS [1155]|BCBS UTHCT [115568]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|426||||426|126.31|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|CIGNA [1260]|CIGNA GWH [126023]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|426||||426|272.64|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|426||||426|351.85|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|426||||426|126.31|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|426||||426|126.31|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|426||||426|126.31|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|426||||426|272.64|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|426||||426|126.31|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|Self-pay|Self-pay|426||||426|149.1|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|426||||426|126.31|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|426||||426|285.13|351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|426||||426||351.85|126.31
36057420|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC COLPOSCOPY ENTIRE VAGINA W/CERVIX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|426||||426||351.85|126.31
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|AARP [1000]|AARP [100000]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|AETNA [1015]|AETNA [101529]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|901||||901|267.15|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|BCBS [1155]|BCBS UTHCT [115568]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|901||||901|267.15|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|CIGNA [1260]|CIGNA GWH [126023]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|901||||901|576.64|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|901||||901|791.76|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|901||||901|267.15|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|901||||901|267.15|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|901||||901|267.15|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|901||||901|576.64|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|901||||901|267.15|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|Self-pay|Self-pay|901||||901|315.35|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|901||||901|267.15|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|901||||901|285.13|791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|901||||901||791.76|267.15
36057500|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY(S) CERVIX OR EXCISION LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|901||||901||791.76|267.15
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|AARP [1000]|AARP [100000]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|AETNA [1015]|AETNA [101529]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|440||||440|130.46|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|BCBS [1155]|BCBS UTHCT [115568]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|440||||440|130.46|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|CIGNA [1260]|CIGNA GWH [126023]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|440||||440|281.6|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|440||||440|212.9|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|440||||440|130.46|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|440||||440|130.46|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|440||||440|130.46|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|440||||440|281.6|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|440||||440|130.46|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|Self-pay|Self-pay|440||||440|154|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|440||||440|130.46|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|440||||440|285.13|285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|440||||440||285.13|130.46
36058100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY OF UTERUS LINING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|440||||440||285.13|130.46
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|AARP [1000]|AARP [100000]|405||||405|119|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|405||||405|257.81|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|AETNA [1015]|AETNA [101529]|405||||405|405|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|405||||405|120.08|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|405||||405|255.26|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|405||||405|255.26|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|BCBS [1155]|BCBS UTHCT [115568]|405||||405|1350|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|405||||405|35.94|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|405||||405|1682|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|405||||405|1800|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|405||||405|120.08|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|405||||405|255.26|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|CIGNA [1260]|CIGNA GWH [126023]|405||||405|405|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|405||||405|259.2|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|405||||405|351.85|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|405||||405|273.38|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|405||||405|405|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|405||||405|120.08|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|405||||405|255.26|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|405||||405|405|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|405||||405|120.08|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|405||||405|120.08|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|405||||405|259.2|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|405||||405|120.08|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|Self-pay|Self-pay|405||||405|141.75|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|405||||405|120.08|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|405||||405|285.13|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|405||||405|119|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|405||||405|255.26|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|405||||405|255.26|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|405||||405|119|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|405||||405|255.26|1800|35.94
36058301|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL OF IUD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|405||||405|510.51|1800|35.94
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|AARP [1000]|AARP [100000]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|AETNA [1015]|AETNA [101529]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|459||||459|136.09|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|BCBS [1155]|BCBS UTHCT [115568]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|459||||459|0|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|459||||459|136.09|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|CIGNA [1260]|CIGNA GWH [126023]|459||||459|0|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|459||||459|293.76|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|459||||459|229.5|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|459||||459|136.09|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|459||||459|136.09|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|459||||459|136.09|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|459||||459|293.76|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|459||||459|136.09|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|Self-pay|Self-pay|459||||459|160.65|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|459||||459|136.09|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|459||||459|136.09|293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|459||||459||293.76|136.09
36058340|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CATH & SALINE/CTRST SONOHYSTER/HYSTEROSALPI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|459||||459||293.76|136.09
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|AARP [1000]|AARP [100000]|997||||997|361|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|997||||997|569.66|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|AETNA [1015]|AETNA [101529]|997||||997|997|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|997||||997|295.61|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|997||||997|564.02|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|997||||997|564.02|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|BCBS [1155]|BCBS UTHCT [115568]|997||||997|1350|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|997||||997|42.12|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|997||||997|1682|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|997||||997|1800|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|997||||997|295.61|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|997||||997|564.02|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|CIGNA [1260]|CIGNA GWH [126023]|997||||997|575|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|997||||997|638.08|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|997||||997|777.46|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|997||||997|604.06|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|997||||997|997|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|997||||997|295.61|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|997||||997|564.02|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|997||||997|997|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|997||||997|295.61|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|997||||997|295.61|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|997||||997|638.08|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|997||||997|295.61|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|Self-pay|Self-pay|997||||997|348.95|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|997||||997|295.61|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|997||||997|285.13|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|997||||997|361|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|997||||997|564.02|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|997||||997|564.02|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|997||||997|361|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|997||||997|564.02|1800|42.12
36060100|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BIOPSY THYROID PERC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|997||||997|1128.03|1800|42.12
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|AARP [1000]|AARP [100000]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|AETNA [1015]|AETNA [101529]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1451||||1451|430.22|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|BCBS [1155]|BCBS UTHCT [115568]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1451||||1451|430.22|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|CIGNA [1260]|CIGNA GWH [126023]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1451||||1451|928.64|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1451||||1451|777.46|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1451||||1451|430.22|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1451||||1451|430.22|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1451||||1451|430.22|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1451||||1451|928.64|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1451||||1451|430.22|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|Self-pay|Self-pay|1451||||1451|507.85|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1451||||1451|430.22|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1451||||1451|285.13|928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1451||||1451||928.64|285.13
36060300|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC ASP AND/OR INJ THYROID CYST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1451||||1451||928.64|285.13
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|AARP [1000]|AARP [100000]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|AETNA [1015]|AETNA [101529]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|863||||863|255.88|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|BCBS [1155]|BCBS UTHCT [115568]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|863||||863|255.88|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|CIGNA [1260]|CIGNA GWH [126023]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|863||||863|552.32|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|863||||863|793.24|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|863||||863|255.88|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|863||||863|255.88|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|863||||863|255.88|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|863||||863|552.32|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|863||||863|255.88|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|Self-pay|Self-pay|863||||863|302.05|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|863||||863|255.88|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|863||||863|285.13|793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|863||||863||793.24|255.88
36062270|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC PUNCTURE SPINAL LUMBAR DIAGNOSTIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|863||||863||793.24|255.88
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|AARP [1000]|AARP [100000]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|AETNA [1015]|AETNA [101529]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2143||||2143|635.4|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|BCBS [1155]|BCBS UTHCT [115568]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2143||||2143|635.4|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|CIGNA [1260]|CIGNA GWH [126023]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2143||||2143|1371.52|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2143||||2143|793.24|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2143||||2143|635.4|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2143||||2143|635.4|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2143||||2143|635.4|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2143||||2143|1371.52|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2143||||2143|635.4|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|Self-pay|Self-pay|2143||||2143|750.05|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2143||||2143|635.4|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2143||||2143|285.13|1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2143||||2143||1371.52|285.13
36062272|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC LUMBAR PUNCTURE THERAPUETIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2143||||2143||1371.52|285.13
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|AARP [1000]|AARP [100000]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|AETNA [1015]|AETNA [101529]|2070||||2070|912.87|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2070||||2070|613.76|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|BCBS [1155]|BCBS UTHCT [115568]|2070||||2070|972.9|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2070||||2070|831.89|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2070||||2070|1035|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2070||||2070|1304.1|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2070||||2070|613.76|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|CIGNA [1260]|CIGNA GWH [126023]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2070||||2070|1428.3|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2070||||2070|893.98|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2070||||2070|912.87|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2070||||2070|613.76|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2070||||2070|912.87|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2070||||2070|613.76|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2070||||2070|613.76|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2070||||2070|1428.3|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2070||||2070|613.76|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|Self-pay|Self-pay|2070||||2070|724.5|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2070||||2070|613.76|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2070||||2070|613.76|1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2070||||2070||1428.3|613.76
36062302|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM C-SPINE W/LUMBAR INJ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|AARP [1000]|AARP [100000]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|AETNA [1015]|AETNA [101529]|2070||||2070|912.87|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2070||||2070|613.76|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|BCBS [1155]|BCBS UTHCT [115568]|2070||||2070|972.9|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2070||||2070|831.89|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2070||||2070|1035|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2070||||2070|1304.1|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2070||||2070|613.76|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|CIGNA [1260]|CIGNA GWH [126023]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2070||||2070|1428.3|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2070||||2070|893.98|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2070||||2070|912.87|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2070||||2070|613.76|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2070||||2070|912.87|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2070||||2070|613.76|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2070||||2070|613.76|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2070||||2070|1428.3|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2070||||2070|613.76|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|Self-pay|Self-pay|2070||||2070|724.5|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2070||||2070|613.76|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2070||||2070|613.76|1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2070||||2070||1428.3|613.76
36062303|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM T-SPINE W/LUMBAR INJ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|AARP [1000]|AARP [100000]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|AETNA [1015]|AETNA [101529]|2070||||2070|912.87|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2070||||2070|613.76|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|BCBS [1155]|BCBS UTHCT [115568]|2070||||2070|972.9|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2070||||2070|831.89|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2070||||2070|1035|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2070||||2070|1304.1|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2070||||2070|613.76|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|CIGNA [1260]|CIGNA GWH [126023]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2070||||2070|1428.3|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2070||||2070|893.98|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2070||||2070|912.87|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2070||||2070|613.76|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2070||||2070|912.87|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2070||||2070|613.76|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2070||||2070|613.76|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2070||||2070|1428.3|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2070||||2070|613.76|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|Self-pay|Self-pay|2070||||2070|724.5|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2070||||2070|613.76|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2070||||2070|613.76|1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2070||||2070||1428.3|613.76
36062304|EAP|0320 - RADIOLOGY-DIAGNOSTIC-GENERAL|HC MYELOGRAM L-S SPINE W/LUMBAR INJ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2070||||2070||1428.3|613.76
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|AARP [1000]|AARP [100000]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|AETNA [1015]|AETNA [101529]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1607||||1607|476.48|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|BCBS [1155]|BCBS UTHCT [115568]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1607||||1607|476.48|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|CIGNA [1260]|CIGNA GWH [126023]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1607||||1607|1028.48|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1607||||1607|793.24|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1607||||1607|476.48|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1607||||1607|476.48|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1607||||1607|476.48|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1607||||1607|1028.48|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1607||||1607|476.48|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|Self-pay|Self-pay|1607||||1607|562.45|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1607||||1607|476.48|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1607||||1607|285.13|1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1607||||1607||1028.48|285.13
36062322|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ DX/THRP LUM/SACRL WO IMAGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1607||||1607||1028.48|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|AARP [1000]|AARP [100000]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|AETNA [1015]|AETNA [101529]|1689||||1689|1689|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1689||||1689|500.79|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|BCBS [1155]|BCBS UTHCT [115568]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1689||||1689|500.79|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|CIGNA [1260]|CIGNA GWH [126023]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1689||||1689|1080.96|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1689||||1689|793.24|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1689||||1689|1689|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1689||||1689|500.79|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1689||||1689|1689|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1689||||1689|500.79|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1689||||1689|500.79|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1689||||1689|1080.96|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1689||||1689|500.79|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|Self-pay|Self-pay|1689||||1689|591.15|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1689||||1689|500.79|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1689||||1689|285.13|1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1689||||1689||1689|285.13
36062328|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1689||||1689||1689|285.13
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|AARP [1000]|AARP [100000]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|AETNA [1015]|AETNA [101529]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|775||||775|229.79|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|BCBS [1155]|BCBS UTHCT [115568]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|775||||775|229.79|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|CIGNA [1260]|CIGNA GWH [126023]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|775||||775|496|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|775||||775|326.46|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|775||||775|229.79|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|775||||775|229.79|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|775||||775|229.79|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|775||||775|496|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|775||||775|229.79|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|Self-pay|Self-pay|775||||775|271.25|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|775||||775|229.79|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|775||||775|285.13|496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|775||||775||496|229.79
36064400|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE TRIGEMINAL EA BRANCH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|775||||775||496|229.79
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|AARP [1000]|AARP [100000]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|AETNA [1015]|AETNA [101529]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|600||||600|177.9|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|BCBS [1155]|BCBS UTHCT [115568]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|600||||600|177.9|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|CIGNA [1260]|CIGNA GWH [126023]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|600||||600|384|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|600||||600|326.46|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|600||||600|177.9|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|600||||600|177.9|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|600||||600|177.9|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|600||||600|384|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|600||||600|177.9|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|Self-pay|Self-pay|600||||600|210|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|600||||600|177.9|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|600||||600|285.13|384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|600||||600||384|177.9
36064405|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE GREATER OCCIPITAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|600||||600||384|177.9
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|AARP [1000]|AARP [100000]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|AETNA [1015]|AETNA [101529]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2930||||2930|868.75|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|BCBS [1155]|BCBS UTHCT [115568]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2930||||2930|868.75|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|CIGNA [1260]|CIGNA GWH [126023]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2930||||2930|1875.2|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2930||||2930|1028.08|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2930||||2930|868.75|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2930||||2930|868.75|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2930||||2930|868.75|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2930||||2930|1875.2|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2930||||2930|868.75|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|Self-pay|Self-pay|2930||||2930|1025.5|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2930||||2930|868.75|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2930||||2930|285.13|1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2930||||2930||1875.2|285.13
36064421|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE INTERCOSTAL EA ADDL LVL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2930||||2930||1875.2|285.13
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|AARP [1000]|AARP [100000]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|AETNA [1015]|AETNA [101529]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|752||||752|222.97|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|BCBS [1155]|BCBS UTHCT [115568]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|752||||752|222.97|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|CIGNA [1260]|CIGNA GWH [126023]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|752||||752|481.28|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|752||||752|793.24|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|752||||752|222.97|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|752||||752|222.97|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|752||||752|222.97|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|752||||752|481.28|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|752||||752|222.97|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|Self-pay|Self-pay|752||||752|263.2|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|752||||752|222.97|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|752||||752|285.13|793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|752||||752||793.24|222.97
36064450|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ NERVE OTHER PERIPHERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|752||||752||793.24|222.97
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|AARP [1000]|AARP [100000]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|AETNA [1015]|AETNA [101529]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|594||||594|176.12|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|BCBS [1155]|BCBS UTHCT [115568]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|594||||594|176.12|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|CIGNA [1260]|CIGNA GWH [126023]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|594||||594|380.16|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|594||||594|326.46|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|594||||594|176.12|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|594||||594|176.12|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|594||||594|176.12|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|594||||594|380.16|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|594||||594|176.12|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|Self-pay|Self-pay|594||||594|207.9|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|594||||594|176.12|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|594||||594|285.13|380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|594||||594||380.16|176.12
36064455|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC US INJ ANES/STEROID PLANTAR NERVE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|594||||594||380.16|176.12
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|AARP [1000]|AARP [100000]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|AETNA [1015]|AETNA [101529]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|400||||400|118.6|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|BCBS [1155]|BCBS UTHCT [115568]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|400||||400|0|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|400||||400|118.6|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|CIGNA [1260]|CIGNA GWH [126023]|400||||400|0|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|400||||400|256|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|400||||400|200|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|400||||400|118.6|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|400||||400|118.6|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|400||||400|118.6|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|400||||400|256|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|400||||400|118.6|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|Self-pay|Self-pay|400||||400|140|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|400||||400|118.6|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|400||||400|118.6|256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|400||||400||256|118.6
36064494|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC INJ PARAVERT LUMB/SACRAL 2ND LVL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|400||||400||256|118.6
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|AARP [1000]|AARP [100000]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|AETNA [1015]|AETNA [101529]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|566||||566|167.82|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|BCBS [1155]|BCBS UTHCT [115568]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|566||||566|167.82|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|CIGNA [1260]|CIGNA GWH [126023]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|566||||566|362.24|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|566||||566|326.46|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|566||||566|167.82|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|566||||566|167.82|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|566||||566|167.82|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|566||||566|362.24|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|566||||566|167.82|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|Self-pay|Self-pay|566||||566|198.1|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|566||||566|167.82|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|566||||566|167.82|362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|566||||566||362.24|167.82
36064566|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC POST TIB NEUROSTIM PERC NDL ELECTRD SGL TX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|566||||566||362.24|167.82
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|AARP [1000]|AARP [100000]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|AETNA [1015]|AETNA [101529]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|404||||404|119.79|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|BCBS [1155]|BCBS UTHCT [115568]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|404||||404|119.79|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|CIGNA [1260]|CIGNA GWH [126023]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|GROUP PENSION ADMIN [1450]|GPA [145000]|404||||404|258.56|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|404||||404|326.46|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|404||||404|119.79|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|404||||404|119.79|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|404||||404|119.79|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|PHCS [1780]|PHCS MULTIPLAN [178000]|404||||404|258.56|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|404||||404|119.79|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|Self-pay|Self-pay|404||||404|141.4|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|404||||404|119.79|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|404||||404|285.13|326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|404||||404||326.46|119.79
36064612|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTROY NERVE FACIAL MUSCLE UNI|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|404||||404||326.46|119.79
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|AARP [1000]|AARP [100000]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|AETNA [1015]|AETNA [101529]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|600||||600|177.9|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|BCBS [1155]|BCBS UTHCT [115568]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|600||||600|177.9|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|CIGNA [1260]|CIGNA GWH [126023]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|600||||600|384|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|600||||600|326.46|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|600||||600|177.9|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|600||||600|177.9|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|600||||600|177.9|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|600||||600|384|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|600||||600|177.9|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|Self-pay|Self-pay|600||||600|210|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|600||||600|177.9|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|600||||600|31.17|384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|600||||600||384|31.17
36064616|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC CHEMODENERV MUSC NECK UNILAT FOR DYSTON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|600||||600||384|31.17
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|AARP [1000]|AARP [100000]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|AETNA [1015]|AETNA [101529]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1489||||1489|441.49|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|BCBS [1155]|BCBS UTHCT [115568]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1489||||1489|441.49|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|CIGNA [1260]|CIGNA GWH [126023]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1489||||1489|952.96|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1489||||1489|1028.08|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1489||||1489|441.49|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1489||||1489|441.49|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1489||||1489|441.49|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1489||||1489|952.96|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1489||||1489|441.49|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|Self-pay|Self-pay|1489||||1489|521.15|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1489||||1489|441.49|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1489||||1489|285.13|1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1489||||1489||1028.08|285.13
36064640|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DESTRUCT PERIPHERAL NERVE/BRANCH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1489||||1489||1028.08|285.13
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|AARP [1000]|AARP [100000]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|AETNA [1015]|AETNA [101529]|286||||286|286|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|286||||286|84.8|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|BCBS [1155]|BCBS UTHCT [115568]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|286||||286|84.8|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|CIGNA [1260]|CIGNA GWH [126023]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|286||||286|183.04|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|286||||286|139.94|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|286||||286|286|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|286||||286|84.8|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|286||||286|286|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|286||||286|84.8|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|286||||286|84.8|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|286||||286|183.04|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|286||||286|84.8|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|Self-pay|Self-pay|286||||286|100.1|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|286||||286|84.8|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|286||||286|84.8|286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|286||||286||286|84.8
36065205|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVAL FB CONJUNCTIVAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|286||||286||286|84.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|AARP [1000]|AARP [100000]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|AETNA [1015]|AETNA [101529]|313||||313|313|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|313||||313|92.8|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|BCBS [1155]|BCBS UTHCT [115568]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|313||||313|92.8|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|CIGNA [1260]|CIGNA GWH [126023]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|313||||313|200.32|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|313||||313|337.78|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|313||||313|313|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|313||||313|92.8|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|313||||313|313|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|313||||313|92.8|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|313||||313|92.8|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|313||||313|200.32|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|313||||313|92.8|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|Self-pay|Self-pay|313||||313|109.55|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|313||||313|92.8|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|313||||313|92.8|337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|313||||313||337.78|92.8
36065220|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB CORNEAL W/O SLIT LAMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|313||||313||337.78|92.8
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|AARP [1000]|AARP [100000]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|AETNA [1015]|AETNA [101529]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|723||||723|214.37|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|BCBS [1155]|BCBS UTHCT [115568]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|723||||723|214.37|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|CIGNA [1260]|CIGNA GWH [126023]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|GROUP PENSION ADMIN [1450]|GPA [145000]|723||||723|462.72|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|723||||723|326.6|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|723||||723|214.37|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|723||||723|214.37|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|723||||723|214.37|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|PHCS [1780]|PHCS MULTIPLAN [178000]|723||||723|462.72|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|723||||723|214.37|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|Self-pay|Self-pay|723||||723|253.05|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|723||||723|214.37|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|723||||723|285.13|462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|723||||723||462.72|214.37
36067700|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC BLEPHAROTOMY DRAIN ABSC EYELID|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|723||||723||462.72|214.37
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|AARP [1000]|AARP [100000]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|AETNA [1015]|AETNA [101529]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1881||||1881|557.72|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|BCBS [1155]|BCBS UTHCT [115568]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1881||||1881|557.72|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|CIGNA [1260]|CIGNA GWH [126023]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1881||||1881|1203.84|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1881||||1881|1011.93|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1881||||1881|557.72|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1881||||1881|557.72|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1881||||1881|557.72|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1881||||1881|1203.84|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1881||||1881|557.72|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|Self-pay|Self-pay|1881||||1881|658.35|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1881||||1881|557.72|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1881||||1881|285.13|1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1881||||1881||1203.84|285.13
36067840|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE EYELID LESION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1881||||1881||1203.84|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|AARP [1000]|AARP [100000]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|AETNA [1015]|AETNA [101529]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3330||||3330|987.35|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|BCBS [1155]|BCBS UTHCT [115568]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3330||||3330|987.35|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|CIGNA [1260]|CIGNA GWH [126023]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3330||||3330|2131.2|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3330||||3330|1758.75|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3330||||3330|987.35|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3330||||3330|987.35|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3330||||3330|987.35|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3330||||3330|2131.2|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3330||||3330|987.35|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|Self-pay|Self-pay|3330||||3330|1165.5|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3330||||3330|987.35|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3330||||3330|285.13|2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3330||||3330||2131.2|285.13
36069005|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DRAIN EXTERNAL EAR COMPLICATED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3330||||3330||2131.2|285.13
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|AARP [1000]|AARP [100000]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|AETNA [1015]|AETNA [101529]|216||||216|216|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|216||||216|64.04|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|BCBS [1155]|BCBS UTHCT [115568]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|216||||216|64.04|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|CIGNA [1260]|CIGNA GWH [126023]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|GROUP PENSION ADMIN [1450]|GPA [145000]|216||||216|138.24|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|216||||216|139.94|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|216||||216|216|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|216||||216|64.04|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|216||||216|216|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|216||||216|64.04|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|216||||216|64.04|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|PHCS [1780]|PHCS MULTIPLAN [178000]|216||||216|138.24|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|216||||216|64.04|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|Self-pay|Self-pay|216||||216|75.6|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|216||||216|64.04|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|216||||216|64.04|216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|216||||216||216|64.04
36069200|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMV FB EXT AUDITORY CANAL W/|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|216||||216||216|64.04
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|AARP [1000]|AARP [100000]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|AETNA [1015]|AETNA [101529]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|150||||150|44.48|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|BCBS [1155]|BCBS UTHCT [115568]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|150||||150|44.48|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|CIGNA [1260]|CIGNA GWH [126023]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|150||||150|96|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|150||||150|69.58|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|150||||150|44.48|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|150||||150|44.48|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|150||||150|44.48|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|150||||150|96|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|150||||150|44.48|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|Self-pay|Self-pay|150||||150|52.5|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|150||||150|44.48|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|150||||150|44.48|96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|150||||150||96|44.48
36069209|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN IRRIGATION/LVG UNILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|150||||150||96|44.48
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|AARP [1000]|AARP [100000]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|AETNA [1015]|AETNA [101529]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|225||||225|66.71|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|BCBS [1155]|BCBS UTHCT [115568]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|225||||225|66.71|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|CIGNA [1260]|CIGNA GWH [126023]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|225||||225|144|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|225||||225|69.58|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|225||||225|66.71|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|225||||225|66.71|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|225||||225|66.71|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|225||||225|144|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|225||||225|66.71|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|Self-pay|Self-pay|225||||225|78.75|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|225||||225|66.71|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|225||||225|66.71|144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|225||||225||144|66.71
36069210|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC REMOVE IMPACTED CERUMEN INSTRUMENTATION UNILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|225||||225||144|66.71
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|AARP [1000]|AARP [100000]|394||||394|119|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|394||||394|164.44|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|AETNA [1015]|AETNA [101529]|394||||394|394|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|394||||394|116.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|394||||394|162.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|394||||394|162.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|BCBS [1155]|BCBS UTHCT [115568]|394||||394||394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|394||||394|29.77|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|394||||394||394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|394||||394||394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|394||||394|116.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|394||||394|162.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|CIGNA [1260]|CIGNA GWH [126023]|394||||394|0|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|394||||394|252.16|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|394||||394|224.44|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|394||||394|174.38|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|394||||394|394|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|394||||394|116.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|394||||394|162.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|394||||394|394|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|394||||394|116.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|394||||394|116.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|394||||394|252.16|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|394||||394|116.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|Self-pay|Self-pay|394||||394|137.9|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|394||||394|116.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|394||||394|116.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|394||||394|119|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|394||||394|162.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|394||||394|162.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|394||||394|119|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|394||||394|162.82|394|29.77
36097597|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC DEBRIDE OPEN WOUND <=20 SQ CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|394||||394|325.63|394|29.77
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|AARP [1000]|AARP [100000]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|AETNA [1015]|AETNA [101529]|245||||245|245|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|245||||245|72.64|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|BCBS [1155]|BCBS UTHCT [115568]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|245||||245|206.12|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|245||||245|72.64|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|CIGNA [1260]|CIGNA GWH [126023]|245||||245|0|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|245||||245|156.8|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|245||||245|224.44|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|245||||245|245|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|245||||245|72.64|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|245||||245|245|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|245||||245|72.64|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|245||||245|72.64|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|245||||245|156.8|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|245||||245|72.64|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|Self-pay|Self-pay|245||||245|85.75|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|245||||245|72.64|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|245||||245|72.64|245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|245||||245||245|72.64
36097605|EAP|0360 - OPERATING ROOM SERVICES-GENERAL|HC NEG PRESSURE WND TX DME </= 50 SQ CM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|245||||245||245|72.64
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|AARP [1000]|AARP [100000]|3603.26||||3603.26|1194|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3603.26||||3603.26|1141.34|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|AETNA [1015]|AETNA [101529]|3603.26||||3603.26|2713.68|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3603.26||||3603.26|1068.37|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3603.26||||3603.26|1130.04|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3603.26||||3603.26|1130.04|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|BCBS [1155]|BCBS UTHCT [115568]|3603.26||||3603.26|1693.53|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3603.26||||3603.26|0|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3603.26||||3603.26|1801.63|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3603.26||||3603.26|2270.05|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3603.26||||3603.26|1068.37|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3603.26||||3603.26|1130.04|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|CIGNA [1260]|CIGNA GWH [126023]|3603.26||||3603.26|1801.63|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|3603.26||||3603.26|2486.25|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3603.26||||3603.26|46.78|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3603.26||||3603.26|1130.04|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3603.26||||3603.26|2713.68|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3603.26||||3603.26|1068.37|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3603.26||||3603.26|1130.04|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3603.26||||3603.26|2713.68|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3603.26||||3603.26|1068.37|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|3603.26||||3603.26|1068.37|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|3603.26||||3603.26|2486.25|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3603.26||||3603.26|1068.37|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|Self-pay|Self-pay|3603.26||||3603.26|1261.14|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3603.26||||3603.26|1068.37|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3603.26||||3603.26|1068.37|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3603.26||||3603.26|1194|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3603.26||||3603.26|1130.04|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3603.26||||3603.26|1130.04|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3603.26||||3603.26|1194|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3603.26||||3603.26|1130.04|2713.68|46.78
36151|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OMALIZUMAB 150 MG SUBCUTANEOUS SOLUTION|150 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3603.26||||3603.26|2260.08|2713.68|46.78
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.5||||2.5|1.1|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.5||||2.5|0.74|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|2.5||||2.5|1.18|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.5||||2.5|1.25|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.5||||2.5|1.25|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.5||||2.5|1.58|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.5||||2.5|0.74|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|2.5||||2.5|1.38|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.5||||2.5|1.73|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.5||||2.5|1.25|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.5||||2.5|1.1|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.5||||2.5|0.74|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.5||||2.5|1.1|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.5||||2.5|0.74|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.5||||2.5|0.74|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.5||||2.5|1.73|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.5||||2.5|0.74|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.5||||2.5|0.87|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.5||||2.5|0.74|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.5||||2.5|0.74|1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.5||||2.5||1.73|0.74
364|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.5||||2.5||1.73|0.74
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|25.47||||25.47|11.23|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.47||||25.47|7.55|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|25.47||||25.47|11.97|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.47||||25.47|12.74|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.47||||25.47|12.74|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.47||||25.47|16.05|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.47||||25.47|7.55|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|25.47||||25.47|14.01|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|25.47||||25.47|17.57|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25.47||||25.47|12.74|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.47||||25.47|11.23|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.47||||25.47|7.55|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.47||||25.47|11.23|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.47||||25.47|7.55|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|25.47||||25.47|7.55|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|25.47||||25.47|17.57|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.47||||25.47|7.55|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|Self-pay|Self-pay|25.47||||25.47|8.91|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25.47||||25.47|7.55|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.47||||25.47|7.55|17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.47||||25.47||17.57|7.55
36438|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.47||||25.47||17.57|7.55
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|AARP [1000]|AARP [100000]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|AETNA [1015]|AETNA [101529]|1.18||||1.18|0.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.18||||1.18|0.35|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|BCBS [1155]|BCBS UTHCT [115568]|1.18||||1.18|0.55|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.18||||1.18|0.59|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.18||||1.18|0.59|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.18||||1.18|0.74|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.18||||1.18|0.35|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|CIGNA [1260]|CIGNA GWH [126023]|1.18||||1.18|0.65|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.18||||1.18|0.81|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.18||||1.18|0.59|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.18||||1.18|0.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.18||||1.18|0.35|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.18||||1.18|0.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.18||||1.18|0.35|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.18||||1.18|0.35|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.18||||1.18|0.81|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.18||||1.18|0.35|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|Self-pay|Self-pay|1.18||||1.18|0.41|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.18||||1.18|0.35|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.18||||1.18|0.35|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.18||||1.18||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|AARP [1000]|AARP [100000]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|AETNA [1015]|AETNA [101529]|55.72||||55.72|24.57|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55.72||||55.72|16.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|BCBS [1155]|BCBS UTHCT [115568]|55.72||||55.72|26.19|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|55.72||||55.72|27.86|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|55.72||||55.72|27.86|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|55.72||||55.72|35.1|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|55.72||||55.72|16.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|CIGNA [1260]|CIGNA GWH [126023]|55.72||||55.72|30.65|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|55.72||||55.72|38.45|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|55.72||||55.72|27.86|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55.72||||55.72|24.57|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|55.72||||55.72|16.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55.72||||55.72|24.57|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|55.72||||55.72|16.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|55.72||||55.72|16.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|55.72||||55.72|38.45|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|55.72||||55.72|16.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|Self-pay|Self-pay|55.72||||55.72|19.5|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|55.72||||55.72|16.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|55.72||||55.72|16.52|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|55.72||||55.72||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|AARP [1000]|AARP [100000]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|AETNA [1015]|AETNA [101529]|0.59||||0.59|0.26|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.59||||0.59|0.17|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.59||||0.59|0.28|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.59||||0.59|0.3|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.59||||0.59|0.3|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.59||||0.59|0.37|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.59||||0.59|0.17|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.59||||0.59|0.32|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.59||||0.59|0.41|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.59||||0.59|0.3|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.59||||0.59|0.26|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.59||||0.59|0.17|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.59||||0.59|0.26|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.59||||0.59|0.17|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.59||||0.59|0.17|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.59||||0.59|0.41|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.59||||0.59|0.17|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|Self-pay|Self-pay|0.59||||0.59|0.21|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.59||||0.59|0.17|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.59||||0.59|0.17|38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.59||||0.59||38.45|0.17
365|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMANTADINE HCL 50 MG/5 ML ORAL SOLUTION REPACK|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.59||||0.59||38.45|0.17
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|620||||620|243.9|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|620||||620||427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|620||||620|90.24|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|620||||620|183.83|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|620||||620||427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|620||||620||427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|620||||620|291.4|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|620||||620|0|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|620||||620|310|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|620||||620|390.6|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|620||||620|183.83|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|620||||620||427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|620||||620|310|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|620||||620|427.8|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|620||||620|3.99|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|620||||620||427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|620||||620|90.24|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|620||||620|183.83|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|620||||620||427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|620||||620|90.24|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|620||||620|183.83|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|620||||620|183.83|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|620||||620|427.8|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|620||||620|183.83|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|620||||620|217|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|620||||620|183.83|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|620||||620|183.83|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|620||||620|243.9|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|620||||620||427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|620||||620||427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|620||||620|243.9|427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|620||||620||427.8|3.99
36591|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|620||||620||427.8|3.99
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.59||||0.59|0.26|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.59||||0.59|0.17|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.59||||0.59|0.28|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.59||||0.59|0.3|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.59||||0.59|0.3|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.59||||0.59|0.37|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.59||||0.59|0.17|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.59||||0.59|0.32|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.59||||0.59|0.41|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.59||||0.59|0.3|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.59||||0.59|0.26|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.59||||0.59|0.17|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.59||||0.59|0.26|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.59||||0.59|0.17|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.59||||0.59|0.17|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.59||||0.59|0.41|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.59||||0.59|0.17|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.59||||0.59|0.21|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.59||||0.59|0.17|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.59||||0.59|0.17|0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.59||||0.59||0.41|0.17
36612|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROSUVASTATIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.59||||0.59||0.41|0.17
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|5.74||||5.74|2.53|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.74||||5.74|1.7|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.74||||5.74|2.7|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.74||||5.74|2.87|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.74||||5.74|2.87|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.74||||5.74|3.62|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.74||||5.74|1.7|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.74||||5.74|3.16|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.74||||5.74|3.96|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.74||||5.74|2.87|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.74||||5.74|2.53|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.74||||5.74|1.7|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.74||||5.74|2.53|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.74||||5.74|1.7|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.74||||5.74|1.7|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.74||||5.74|3.96|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.74||||5.74|1.7|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|5.74||||5.74|2.01|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.74||||5.74|1.7|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.74||||5.74|1.7|3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.74||||5.74||3.96|1.7
36775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.74||||5.74||3.96|1.7
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|7.85||||7.85|3.46|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.85||||7.85|2.33|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|7.85||||7.85|3.69|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.85||||7.85|3.93|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.85||||7.85|3.93|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.85||||7.85|4.95|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.85||||7.85|2.33|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|7.85||||7.85|4.32|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.85||||7.85|5.42|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.85||||7.85|3.93|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.85||||7.85|3.46|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.85||||7.85|2.33|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.85||||7.85|3.46|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.85||||7.85|2.33|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.85||||7.85|2.33|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.85||||7.85|5.42|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.85||||7.85|2.33|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|7.85||||7.85|2.75|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.85||||7.85|2.33|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.85||||7.85|2.33|5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.85||||7.85||5.42|2.33
36776|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL XL 300 MG 24 HR TABLET, EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.85||||7.85||5.42|2.33
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.41||||19.41|8.56|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.41||||19.41|5.76|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|19.41||||19.41|9.12|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.41||||19.41|9.71|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.41||||19.41|9.71|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.41||||19.41|12.23|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.41||||19.41|5.76|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|19.41||||19.41|10.68|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.41||||19.41|13.39|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.41||||19.41|9.71|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.41||||19.41|8.56|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.41||||19.41|5.76|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.41||||19.41|8.56|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.41||||19.41|5.76|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.41||||19.41|5.76|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.41||||19.41|13.39|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.41||||19.41|5.76|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|Self-pay|Self-pay|19.41||||19.41|6.79|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.41||||19.41|5.76|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.41||||19.41|5.76|13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.41||||19.41||13.39|5.76
36959|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.41||||19.41||13.39|5.76
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.07||||2.07|0.91|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.07||||2.07|0.61|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.07||||2.07|0.97|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.07||||2.07|1.04|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.07||||2.07|1.04|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.07||||2.07|1.3|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.07||||2.07|0.61|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.07||||2.07|1.14|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.07||||2.07|1.43|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.07||||2.07|1.04|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.07||||2.07|0.91|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.07||||2.07|0.61|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.07||||2.07|0.91|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.07||||2.07|0.61|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.07||||2.07|0.61|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.07||||2.07|1.43|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.07||||2.07|0.61|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.07||||2.07|0.72|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.07||||2.07|0.61|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.07||||2.07|0.61|1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.07||||2.07||1.43|0.61
36966|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.07||||2.07||1.43|0.61
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|40.55||||40.55|6.91|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40.55||||40.55|12.02|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|40.55||||40.55|19.06|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40.55||||40.55|0|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40.55||||40.55|20.28|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40.55||||40.55|25.55|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40.55||||40.55|12.02|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|40.55||||40.55|22.3|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|40.55||||40.55|27.98|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|40.55||||40.55|3.68|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40.55||||40.55|6.91|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40.55||||40.55|12.02|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40.55||||40.55|6.91|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40.55||||40.55|12.02|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|40.55||||40.55|12.02|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|40.55||||40.55|27.98|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40.55||||40.55|12.02|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|40.55||||40.55|14.19|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|40.55||||40.55|12.02|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40.55||||40.55|12.02|27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40.55||||40.55||27.98|3.68
3697|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDRALAZINE 20 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40.55||||40.55||27.98|3.68
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|AARP [1000]|AARP [100000]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|AETNA [1015]|AETNA [101529]|5.49||||5.49|2.42|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.49||||5.49|1.63|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|BCBS [1155]|BCBS UTHCT [115568]|5.49||||5.49|2.58|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.49||||5.49|2.75|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.49||||5.49|2.75|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.49||||5.49|3.46|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.49||||5.49|1.63|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|CIGNA [1260]|CIGNA GWH [126023]|5.49||||5.49|3.02|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.49||||5.49|3.79|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.49||||5.49|2.75|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.49||||5.49|2.42|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.49||||5.49|1.63|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.49||||5.49|2.42|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.49||||5.49|1.63|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.49||||5.49|1.63|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.49||||5.49|3.79|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.49||||5.49|1.63|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|Self-pay|Self-pay|5.49||||5.49|1.92|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.49||||5.49|1.63|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.49||||5.49|1.63|3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.49||||5.49||3.79|1.63
36976|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOL 1.4 % MUCOSAL AEROSOL SPRAY|177 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.49||||5.49||3.79|1.63
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.53||||0.53|0.23|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.53||||0.53|0.16|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.53||||0.53|0.25|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.53||||0.53|0.27|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.53||||0.53|0.27|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.53||||0.53|0.33|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.53||||0.53|0.16|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.53||||0.53|0.29|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.53||||0.53|0.37|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.53||||0.53|0.27|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.53||||0.53|0.23|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.53||||0.53|0.16|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.53||||0.53|0.23|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.53||||0.53|0.16|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.53||||0.53|0.16|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.53||||0.53|0.37|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.53||||0.53|0.16|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.53||||0.53|0.19|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.53||||0.53|0.16|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.53||||0.53|0.16|0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.53||||0.53||0.37|0.16
3698|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.53||||0.53||0.37|0.16
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|1.24||||1.24|0.55|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.24||||1.24|0.37|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.24||||1.24|0.58|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.24||||1.24|0.62|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.24||||1.24|0.62|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.24||||1.24|0.78|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.24||||1.24|0.37|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.24||||1.24|0.68|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.24||||1.24|0.86|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.24||||1.24|0.62|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.24||||1.24|0.55|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.24||||1.24|0.37|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.24||||1.24|0.55|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.24||||1.24|0.37|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.24||||1.24|0.37|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.24||||1.24|0.86|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.24||||1.24|0.37|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|1.24||||1.24|0.43|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.24||||1.24|0.37|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.24||||1.24|0.37|0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.24||||1.24||0.86|0.37
36982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALFUZOSIN ER 10 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.24||||1.24||0.86|0.37
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|1381.02||||1381.02|395|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1381.02||||1381.02||952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|1381.02||||1381.02|168|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1381.02||||1381.02|409.47|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1381.02||||1381.02||952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1381.02||||1381.02||952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|1381.02||||1381.02|649.08|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1381.02||||1381.02|0|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1381.02||||1381.02|690.51|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1381.02||||1381.02|870.04|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1381.02||||1381.02|409.47|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1381.02||||1381.02||952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|1381.02||||1381.02|690.51|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1381.02||||1381.02|952.9|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1381.02||||1381.02|0.16|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1381.02||||1381.02||952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1381.02||||1381.02|168|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1381.02||||1381.02|409.47|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1381.02||||1381.02||952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1381.02||||1381.02|168|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1381.02||||1381.02|409.47|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|1381.02||||1381.02|409.47|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1381.02||||1381.02|952.9|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1381.02||||1381.02|409.47|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|1381.02||||1381.02|483.36|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1381.02||||1381.02|409.47|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1381.02||||1381.02|409.47|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1381.02||||1381.02|395|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1381.02||||1381.02||952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1381.02||||1381.02||952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1381.02||||1381.02|395|952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1381.02||||1381.02||952.9|0.16
36989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DAPTOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1381.02||||1381.02||952.9|0.16
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.75||||0.75|0.33|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.75||||0.75|0.22|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.75||||0.75|0.35|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.75||||0.75|0.38|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.75||||0.75|0.38|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.75||||0.75|0.47|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.75||||0.75|0.22|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.75||||0.75|0.41|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.75||||0.75|0.52|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.75||||0.75|0.38|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.75||||0.75|0.33|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.75||||0.75|0.22|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.75||||0.75|0.33|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.75||||0.75|0.22|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.75||||0.75|0.22|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.75||||0.75|0.52|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.75||||0.75|0.22|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.75||||0.75|0.26|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.75||||0.75|0.22|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.75||||0.75|0.22|0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.75||||0.75||0.52|0.22
3700|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDRALAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.75||||0.75||0.52|0.22
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AARP [1000]|AARP [100000]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AETNA [1015]|AETNA [101529]|702||||702|309.58|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|702||||702|208.14|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|702||||702|329.94|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|702||||702|351|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|702||||702|351|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|702||||702|442.26|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|702||||702|208.14|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|702||||702|386.1|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|702||||702|484.38|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|702||||702|351|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|702||||702|309.58|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|702||||702|208.14|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|702||||702|309.58|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|702||||702|208.14|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|702||||702|208.14|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|702||||702|484.38|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|702||||702|208.14|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|Self-pay|Self-pay|702||||702|245.7|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|702||||702|208.14|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|702||||702|208.14|484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|702||||702||484.38|208.14
37000006|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I 1ST 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|702||||702||484.38|208.14
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AARP [1000]|AARP [100000]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AETNA [1015]|AETNA [101529]|176||||176|77.62|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|176||||176|52.18|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|176||||176|82.72|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|176||||176|88|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|176||||176|88|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|176||||176|110.88|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|176||||176|52.18|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|176||||176|96.8|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|176||||176|121.44|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|176||||176|88|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|176||||176|77.62|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|176||||176|52.18|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|176||||176|77.62|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|176||||176|52.18|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|176||||176|52.18|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|176||||176|121.44|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|176||||176|52.18|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|Self-pay|Self-pay|176||||176|61.6|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|176||||176|52.18|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|176||||176|52.18|121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|176||||176||121.44|52.18
37000007|EAP|0370 - ANESTHESIA-GENERAL|HC ANES GENERAL LVL I ADDL 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|176||||176||121.44|52.18
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|AARP [1000]|AARP [100000]|493||||493|221.85|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|493||||493||340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|AETNA [1015]|AETNA [101529]|493||||493|217.41|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|493||||493|146.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|493||||493||340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|493||||493||340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|BCBS [1155]|BCBS UTHCT [115568]|493||||493|231.71|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|493||||493|7|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|493||||493|246.5|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|493||||493|310.59|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|493||||493|146.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|493||||493||340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|CIGNA [1260]|CIGNA GWH [126023]|493||||493|271.15|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|493||||493|340.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|493||||493|246.5|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|493||||493||340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|493||||493|217.41|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|493||||493|146.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|493||||493||340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|493||||493|217.41|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|493||||493|146.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|493||||493|146.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|493||||493|340.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|493||||493|146.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|Self-pay|Self-pay|493||||493|172.55|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|493||||493|146.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|493||||493|146.17|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|493||||493|221.85|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|493||||493||340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|493||||493||340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|493||||493|221.85|340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|493||||493||340.17|7
37000500|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDAT GI ENDO >=5YR 1ST 15MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|493||||493||340.17|7
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|AARP [1000]|AARP [100000]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|AETNA [1015]|AETNA [101529]|488||||488|215.21|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|488||||488|144.69|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|BCBS [1155]|BCBS UTHCT [115568]|488||||488|229.36|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|488||||488|30.65|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|488||||488|244|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|488||||488|307.44|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|488||||488|144.69|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|CIGNA [1260]|CIGNA GWH [126023]|488||||488|268.4|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|488||||488|336.72|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|488||||488|244|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|488||||488|215.21|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|488||||488|144.69|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|488||||488|215.21|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|488||||488|144.69|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|488||||488|144.69|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|488||||488|336.72|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|488||||488|144.69|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|Self-pay|Self-pay|488||||488|170.8|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|488||||488|144.69|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|488||||488|144.69|336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|488||||488||336.72|30.65
37099151|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION INTL 15 MIN <5YRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|488||||488||336.72|30.65
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AARP [1000]|AARP [100000]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AETNA [1015]|AETNA [101529]|511||||511|225.35|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|511||||511|151.51|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|511||||511|240.17|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|511||||511|15.76|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|511||||511|255.5|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|511||||511|321.93|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|511||||511|151.51|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|511||||511|281.05|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|511||||511|352.59|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|511||||511|255.5|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|511||||511|225.35|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|511||||511|151.51|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|511||||511|225.35|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|511||||511|151.51|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|511||||511|151.51|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|511||||511|352.59|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|511||||511|151.51|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|Self-pay|Self-pay|511||||511|178.85|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|511||||511|151.51|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|511||||511|151.51|352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|511||||511||352.59|15.76
37099152|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION >=5YR 1ST 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|511||||511||352.59|15.76
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AARP [1000]|AARP [100000]|300||||300|135|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AETNA [1015]|AETNA [101529]|300||||300|132.3|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|88.95|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|13.58|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|88.95|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|165|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|150|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|132.3|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|88.95|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|132.3|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|88.95|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|88.95|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|88.95|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|Self-pay|Self-pay|300||||300|105|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|88.95|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|88.95|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|135|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|135|207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||207|13.58
37099153|EAP|0370 - ANESTHESIA-GENERAL|HC MOD SEDATION EA ADDL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||207|13.58
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.5||||1.5|0.66|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.5||||1.5|0.44|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.5||||1.5|0.71|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.5||||1.5|0.75|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.5||||1.5|0.75|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.5||||1.5|0.95|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.5||||1.5|0.44|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.5||||1.5|0.83|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.5||||1.5|1.04|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.5||||1.5|0.75|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.5||||1.5|0.66|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.5||||1.5|0.44|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.5||||1.5|0.66|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.5||||1.5|0.44|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.5||||1.5|0.44|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.5||||1.5|1.04|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.5||||1.5|0.44|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.5||||1.5|0.52|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.5||||1.5|0.44|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.5||||1.5|0.44|1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.5||||1.5||1.04|0.44
37170|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEMANTINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.5||||1.5||1.04|0.44
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.07||||0.07|0.03|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.07||||0.07|0.02|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.07||||0.07|0.03|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.07||||0.07|0.04|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.07||||0.07|0.04|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.07||||0.07|0.04|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.07||||0.07|0.02|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.07||||0.07|0.04|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.07||||0.07|0.05|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.07||||0.07|0.04|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.07||||0.07|0.03|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.07||||0.07|0.02|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.07||||0.07|0.03|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.07||||0.07|0.02|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.07||||0.07|0.02|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.07||||0.07|0.05|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.07||||0.07|0.02|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.07||||0.07|0.02|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.07||||0.07|0.02|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.07||||0.07|0.02|0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.07||||0.07||0.05|0.02
3720|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.07||||0.07||0.05|0.02
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AARP [1000]|AARP [100000]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AETNA [1015]|AETNA [101529]|1652.03||||1652.03|1252.8|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1652.03||||1652.03|489.83|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|1652.03||||1652.03|776.45|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1652.03||||1652.03|0|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1652.03||||1652.03|826.02|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1652.03||||1652.03|1040.78|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1652.03||||1652.03|489.83|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|1652.03||||1652.03|826.02|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1652.03||||1652.03|1139.9|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1652.03||||1652.03|13.16|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1652.03||||1652.03|1252.8|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1652.03||||1652.03|489.83|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1652.03||||1652.03|1252.8|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1652.03||||1652.03|489.83|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1652.03||||1652.03|489.83|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1652.03||||1652.03|1139.9|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1652.03||||1652.03|489.83|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|Self-pay|Self-pay|1652.03||||1652.03|578.21|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1652.03||||1652.03|489.83|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1652.03||||1652.03|489.83|1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1652.03||||1652.03||1252.8|13.16
37237|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 25 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1652.03||||1652.03||1252.8|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AARP [1000]|AARP [100000]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AETNA [1015]|AETNA [101529]|3304.26||||3304.26|2505.6|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3304.26||||3304.26|979.71|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS [1155]|BCBS UTHCT [115568]|3304.26||||3304.26|1553|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3304.26||||3304.26|0|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3304.26||||3304.26|1652.13|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3304.26||||3304.26|2081.68|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3304.26||||3304.26|979.71|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|CIGNA [1260]|CIGNA GWH [126023]|3304.26||||3304.26|1652.13|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3304.26||||3304.26|2279.94|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3304.26||||3304.26|13.16|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3304.26||||3304.26|2505.6|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3304.26||||3304.26|979.71|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3304.26||||3304.26|2505.6|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3304.26||||3304.26|979.71|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3304.26||||3304.26|979.71|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3304.26||||3304.26|2279.94|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3304.26||||3304.26|979.71|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|Self-pay|Self-pay|3304.26||||3304.26|1156.49|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3304.26||||3304.26|979.71|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3304.26||||3304.26|979.71|2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3304.26||||3304.26||2505.6|13.16
37239|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RISPERIDONE MICROSPHERES ER 50 MG/2 ML INTRAMUSCULAR SUSP,EXT RELEASE|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3304.26||||3304.26||2505.6|13.16
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.89||||0.89|0.39|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.89||||0.89|0.26|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.89||||0.89|0.42|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.89||||0.89|0.45|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.89||||0.89|0.45|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.89||||0.89|0.56|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.89||||0.89|0.26|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.89||||0.89|0.49|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.89||||0.89|0.61|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.89||||0.89|0.45|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.89||||0.89|0.39|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.89||||0.89|0.26|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.89||||0.89|0.39|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.89||||0.89|0.26|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.89||||0.89|0.26|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.89||||0.89|0.61|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.89||||0.89|0.26|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.89||||0.89|0.31|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.89||||0.89|0.26|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.89||||0.89|0.26|0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.89||||0.89||0.61|0.26
3733|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.89||||0.89||0.61|0.26
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.6||||1.6|0.71|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.6||||1.6|0.47|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.6||||1.6|0.75|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.6||||1.6|0.8|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.6||||1.6|0.8|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.6||||1.6|1.01|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.6||||1.6|0.47|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.6||||1.6|0.88|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.6||||1.6|1.1|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.6||||1.6|0.8|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.6||||1.6|0.71|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.6||||1.6|0.47|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.6||||1.6|0.71|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.6||||1.6|0.47|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.6||||1.6|0.47|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.6||||1.6|1.1|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.6||||1.6|0.47|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|Self-pay|Self-pay|1.6||||1.6|0.56|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.6||||1.6|0.47|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.6||||1.6|0.47|1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.6||||1.6||1.1|0.47
3734|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.6||||1.6||1.1|0.47
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|35.65||||35.65|15.72|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.65||||35.65|10.57|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|35.65||||35.65|16.76|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.65||||35.65|17.83|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.65||||35.65|17.83|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.65||||35.65|22.46|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.65||||35.65|10.57|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|35.65||||35.65|19.61|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|35.65||||35.65|24.6|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35.65||||35.65|17.83|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.65||||35.65|15.72|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.65||||35.65|10.57|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.65||||35.65|15.72|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.65||||35.65|10.57|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|35.65||||35.65|10.57|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|35.65||||35.65|24.6|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.65||||35.65|10.57|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|35.65||||35.65|12.48|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35.65||||35.65|10.57|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.65||||35.65|10.57|24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.65||||35.65||24.6|10.57
3738|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCORTISONE ACETATE 25 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.65||||35.65||24.6|10.57
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|AARP [1000]|AARP [100000]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|AETNA [1015]|AETNA [101529]|80.22||||80.22|35.38|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|80.22||||80.22|23.79|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|80.22||||80.22|37.7|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|80.22||||80.22|0|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|80.22||||80.22|40.11|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|80.22||||80.22|50.54|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|80.22||||80.22|23.79|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|80.22||||80.22|44.12|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|80.22||||80.22|55.35|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|80.22||||80.22|31.71|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|80.22||||80.22|35.38|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|80.22||||80.22|23.79|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|80.22||||80.22|35.38|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|80.22||||80.22|23.79|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|80.22||||80.22|23.79|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|80.22||||80.22|55.35|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|80.22||||80.22|23.79|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|Self-pay|Self-pay|80.22||||80.22|28.08|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|80.22||||80.22|23.79|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|80.22||||80.22|23.79|55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|80.22||||80.22||55.35|23.79
37504|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TETANUS-DIPHTHERIA TOXOIDS-TD 2 LF UNIT-2 LF UNIT/0.5 ML IM SUSPENSION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|80.22||||80.22||55.35|23.79
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.46||||0.46|0.2|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.46||||0.46|0.14|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.46||||0.46|0.22|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.46||||0.46|0.23|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.46||||0.46|0.23|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.46||||0.46|0.29|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.46||||0.46|0.14|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.46||||0.46|0.25|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.46||||0.46|0.32|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.46||||0.46|0.23|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.46||||0.46|0.2|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.46||||0.46|0.14|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.46||||0.46|0.2|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.46||||0.46|0.14|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.46||||0.46|0.14|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.46||||0.46|0.32|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.46||||0.46|0.14|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|Self-pay|Self-pay|0.46||||0.46|0.16|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.46||||0.46|0.14|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.46||||0.46|0.14|0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.46||||0.46||0.32|0.14
3760|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROMORPHONE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.46||||0.46||0.32|0.14
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.27||||0.27|0.12|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.27||||0.27|0.08|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.27||||0.27|0.13|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.27||||0.27|0.14|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.27||||0.27|0.14|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.27||||0.27|0.17|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.27||||0.27|0.08|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.27||||0.27|0.15|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.27||||0.27|0.19|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.27||||0.27|0.14|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.27||||0.27|0.12|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.27||||0.27|0.08|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.27||||0.27|0.12|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.27||||0.27|0.08|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.27||||0.27|0.08|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.27||||0.27|0.19|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.27||||0.27|0.08|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.27||||0.27|0.09|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.27||||0.27|0.08|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.27||||0.27|0.08|0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.27||||0.27||0.19|0.08
37637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.27||||0.27||0.19|0.08
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|0.9||||0.9|0.4|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.9||||0.9|0.27|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.9||||0.9|0.42|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.9||||0.9|0.45|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.9||||0.9|0.45|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.9||||0.9|0.57|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.9||||0.9|0.27|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.9||||0.9|0.5|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.9||||0.9|0.62|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.9||||0.9|0.45|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.9||||0.9|0.4|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.9||||0.9|0.27|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.9||||0.9|0.4|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.9||||0.9|0.27|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.9||||0.9|0.27|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.9||||0.9|0.62|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.9||||0.9|0.27|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|0.9||||0.9|0.31|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.9||||0.9|0.27|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.9||||0.9|0.27|0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.9||||0.9||0.62|0.27
37648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 2.5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.9||||0.9||0.62|0.27
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|1.86||||1.86|0.82|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.86||||1.86|0.55|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.86||||1.86|0.87|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.86||||1.86|0.93|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.86||||1.86|0.93|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.86||||1.86|1.17|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.86||||1.86|0.55|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.86||||1.86|1.02|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.86||||1.86|1.28|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.86||||1.86|0.93|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.86||||1.86|0.82|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.86||||1.86|0.55|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.86||||1.86|0.82|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.86||||1.86|0.55|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.86||||1.86|0.55|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.86||||1.86|1.28|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.86||||1.86|0.55|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|1.86||||1.86|0.65|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.86||||1.86|0.55|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.86||||1.86|0.55|1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.86||||1.86||1.28|0.55
37649|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 5 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.86||||1.86||1.28|0.55
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|2.75||||2.75|1.21|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.75||||2.75|0.82|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.75||||2.75|1.29|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.75||||2.75|1.38|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.75||||2.75|1.38|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.75||||2.75|1.73|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.75||||2.75|0.82|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.75||||2.75|1.51|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.75||||2.75|1.9|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.75||||2.75|1.38|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.75||||2.75|1.21|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.75||||2.75|0.82|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.75||||2.75|1.21|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.75||||2.75|0.82|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.75||||2.75|0.82|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.75||||2.75|1.9|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.75||||2.75|0.82|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|2.75||||2.75|0.96|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.75||||2.75|0.82|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.75||||2.75|0.82|1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.75||||2.75||1.9|0.82
37650|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GLIPIZIDE ER 10 MG TABLET, EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.75||||2.75||1.9|0.82
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AARP [1000]|AARP [100000]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AETNA [1015]|AETNA [101529]|1.21||||1.21|0.53|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.21||||1.21|0.36|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.21||||1.21|0.57|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.21||||1.21|0.61|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.21||||1.21|0.61|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.21||||1.21|0.76|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.21||||1.21|0.36|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.21||||1.21|0.67|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.21||||1.21|0.83|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.21||||1.21|0.61|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.21||||1.21|0.53|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.21||||1.21|0.36|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.21||||1.21|0.53|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.21||||1.21|0.36|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.21||||1.21|0.36|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.21||||1.21|0.83|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.21||||1.21|0.36|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|Self-pay|Self-pay|1.21||||1.21|0.42|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.21||||1.21|0.36|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.21||||1.21|0.36|0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.21||||1.21||0.83|0.36
37651|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GUAIFENESIN ER 600 MG TABLET, EXTENDED RELEASE 12 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.21||||1.21||0.83|0.36
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AARP [1000]|AARP [100000]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|72.7||||72.7|33.5|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|72.7||||72.7|21.56|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|72.7||||72.7|34.17|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|72.7||||72.7|0|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|72.7||||72.7|36.35|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|72.7||||72.7|45.8|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|72.7||||72.7|21.56|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|72.7||||72.7|39.99|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|72.7||||72.7|50.16|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|72.7||||72.7|10.38|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|72.7||||72.7|33.5|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|72.7||||72.7|21.56|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|72.7||||72.7|33.5|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|72.7||||72.7|21.56|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|72.7||||72.7|21.56|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|72.7||||72.7|50.16|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|72.7||||72.7|21.56|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|Self-pay|Self-pay|72.7||||72.7|25.44|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|72.7||||72.7|21.56|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|72.7||||72.7|21.56|50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|72.7||||72.7||50.16|10.38
3770|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|72.7||||72.7||50.16|10.38
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|AARP [1000]|AARP [100000]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|AETNA [1015]|AETNA [101529]|5.24||||5.24|2.31|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.24||||5.24|1.55|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|BCBS [1155]|BCBS UTHCT [115568]|5.24||||5.24|2.46|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.24||||5.24|2.62|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.24||||5.24|2.62|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.24||||5.24|3.3|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.24||||5.24|1.55|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|CIGNA [1260]|CIGNA GWH [126023]|5.24||||5.24|2.88|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.24||||5.24|3.62|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.24||||5.24|2.62|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.24||||5.24|2.31|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.24||||5.24|1.55|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.24||||5.24|2.31|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.24||||5.24|1.55|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.24||||5.24|1.55|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.24||||5.24|3.62|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.24||||5.24|1.55|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|Self-pay|Self-pay|5.24||||5.24|1.83|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.24||||5.24|1.55|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.24||||5.24|1.55|3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.24||||5.24||3.62|1.55
3771|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG/5 ML ORAL SOLUTION REPACK|12.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.24||||5.24||3.62|1.55
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.53||||0.53|0.23|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.53||||0.53|0.16|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.53||||0.53|0.25|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.53||||0.53|0.27|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.53||||0.53|0.27|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.53||||0.53|0.33|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.53||||0.53|0.16|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.53||||0.53|0.29|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.53||||0.53|0.37|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.53||||0.53|0.27|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.53||||0.53|0.23|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.53||||0.53|0.16|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.53||||0.53|0.23|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.53||||0.53|0.16|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.53||||0.53|0.16|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.53||||0.53|0.37|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.53||||0.53|0.16|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.53||||0.53|0.19|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.53||||0.53|0.16|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.53||||0.53|0.16|0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.53||||0.53||0.37|0.16
3772|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.53||||0.53||0.37|0.16
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.98||||0.98|0.43|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.98||||0.98|0.29|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.98||||0.98|0.46|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.98||||0.98|0.49|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.98||||0.98|0.49|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.98||||0.98|0.62|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.98||||0.98|0.29|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.98||||0.98|0.54|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.98||||0.98|0.68|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.98||||0.98|0.49|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.98||||0.98|0.43|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.98||||0.98|0.29|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.98||||0.98|0.43|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.98||||0.98|0.29|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.98||||0.98|0.29|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.98||||0.98|0.68|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.98||||0.98|0.29|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.98||||0.98|0.34|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.98||||0.98|0.29|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.98||||0.98|0.29|0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.98||||0.98||0.68|0.29
3774|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.98||||0.98||0.68|0.29
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.45||||0.45|0.2|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.45||||0.45|0.13|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.45||||0.45|0.21|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.45||||0.45|0.23|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.45||||0.45|0.23|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.45||||0.45|0.28|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.45||||0.45|0.13|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.45||||0.45|0.25|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.45||||0.45|0.31|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.45||||0.45|0.23|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.45||||0.45|0.2|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.45||||0.45|0.13|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.45||||0.45|0.2|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.45||||0.45|0.13|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.45||||0.45|0.13|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.45||||0.45|0.31|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.45||||0.45|0.13|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.45||||0.45|0.16|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.45||||0.45|0.13|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.45||||0.45|0.13|0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.45||||0.45||0.31|0.13
3775|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROXYZINE HCL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.45||||0.45||0.31|0.13
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AARP [1000]|AARP [100000]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AARP [1000]|AARP [100000]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AETNA [1015]|AETNA [101529]|3.45||||3.45|1.52|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AETNA [1015]|AETNA [101529]|3.45||||3.45|1.52|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS [1155]|BCBS UTHCT [115568]|3.45||||3.45|1.62|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS [1155]|BCBS UTHCT [115568]|3.45||||3.45|1.62|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.45||||3.45|1.73|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.45||||3.45|1.73|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.45||||3.45|1.73|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.45||||3.45|1.73|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.45||||3.45|2.17|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.45||||3.45|2.17|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|CIGNA [1260]|CIGNA GWH [126023]|3.45||||3.45|1.9|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|CIGNA [1260]|CIGNA GWH [126023]|3.45||||3.45|1.9|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.45||||3.45|2.38|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.45||||3.45|2.38|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.45||||3.45|1.73|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.45||||3.45|1.73|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.45||||3.45|1.52|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.45||||3.45|1.52|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.45||||3.45|1.52|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.45||||3.45|1.52|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.45||||3.45|2.38|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.45||||3.45|2.38|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|Self-pay|Self-pay|3.45||||3.45|1.21|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|Self-pay|Self-pay|3.45||||3.45|1.21|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.45||||3.45|1.02|2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.45||||3.45||2.38|1.02
3781|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR REPACKAGING|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.45||||3.45||2.38|1.02
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|12.7||||12.7|5.6|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.7||||12.7|3.77|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|12.7||||12.7|5.97|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.7||||12.7|6.35|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.7||||12.7|6.35|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.7||||12.7|8|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.7||||12.7|3.77|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|12.7||||12.7|6.99|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.7||||12.7|8.76|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.7||||12.7|6.35|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.7||||12.7|5.6|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.7||||12.7|3.77|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.7||||12.7|5.6|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.7||||12.7|3.77|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.7||||12.7|3.77|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.7||||12.7|8.76|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.7||||12.7|3.77|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|Self-pay|Self-pay|12.7||||12.7|4.44|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.7||||12.7|3.77|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.7||||12.7|3.77|8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.7||||12.7||8.76|3.77
37848|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|HYDROCODONE 7.5 MG-ACETAMINOPHEN 325 MG/15 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.7||||12.7||8.76|3.77
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|11929.67||||11929.67|5964.84|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11929.67||||11929.67|3783.91|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|11929.67||||11929.67|8689.2|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11929.67||||11929.67|3537.15|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11929.67||||11929.67|3746.45|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11929.67||||11929.67|3746.45|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|11929.67||||11929.67|5606.94|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11929.67||||11929.67|0|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11929.67||||11929.67|5964.84|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11929.67||||11929.67|7515.69|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11929.67||||11929.67|3537.15|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11929.67||||11929.67|3746.45|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|11929.67||||11929.67|5964.84|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|11929.67||||11929.67|8231.47|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11929.67||||11929.67|91.49|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11929.67||||11929.67|3746.45|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11929.67||||11929.67|8689.2|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11929.67||||11929.67|3537.15|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11929.67||||11929.67|3746.45|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11929.67||||11929.67|8689.2|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11929.67||||11929.67|3537.15|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|11929.67||||11929.67|3537.15|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|11929.67||||11929.67|8231.47|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11929.67||||11929.67|3537.15|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|11929.67||||11929.67|4175.38|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11929.67||||11929.67|3537.15|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11929.67||||11929.67|3537.15|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11929.67||||11929.67|5964.84|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11929.67||||11929.67|3746.45|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11929.67||||11929.67|3746.45|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11929.67||||11929.67|5964.84|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11929.67||||11929.67|3746.45|8689.2|91.49
37894|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11929.67||||11929.67|7492.9|8689.2|91.49
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|2149.54||||2149.54|688.5|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2149.54||||2149.54|673.72|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|2149.54||||2149.54|1553.04|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2149.54||||2149.54|637.34|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2149.54||||2149.54|667.05|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2149.54||||2149.54|667.05|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|2149.54||||2149.54|1010.28|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2149.54||||2149.54|0|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2149.54||||2149.54|1074.77|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2149.54||||2149.54|1354.21|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2149.54||||2149.54|637.34|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2149.54||||2149.54|667.05|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|2149.54||||2149.54|1074.77|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2149.54||||2149.54|1483.18|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2149.54||||2149.54|81.85|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2149.54||||2149.54|667.05|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2149.54||||2149.54|1553.04|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2149.54||||2149.54|637.34|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2149.54||||2149.54|667.05|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2149.54||||2149.54|1553.04|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2149.54||||2149.54|637.34|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2149.54||||2149.54|637.34|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2149.54||||2149.54|1483.18|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2149.54||||2149.54|637.34|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|2149.54||||2149.54|752.34|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2149.54||||2149.54|637.34|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2149.54||||2149.54|637.34|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2149.54||||2149.54|688.5|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2149.54||||2149.54|667.05|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2149.54||||2149.54|667.05|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2149.54||||2149.54|688.5|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2149.54||||2149.54|667.05|1553.04|81.85
37989|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CETUXIMAB 100 MG/50 ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2149.54||||2149.54|1334.1|1553.04|81.85
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|23.59||||23.59|10.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.59||||23.59|6.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|23.59||||23.59|11.09|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.59||||23.59|0|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.59||||23.59|11.8|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.59||||23.59|14.86|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.59||||23.59|6.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|23.59||||23.59|12.97|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|23.59||||23.59|16.28|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.59||||23.59|2.73|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.59||||23.59|10.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.59||||23.59|6.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.59||||23.59|10.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.59||||23.59|6.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.59||||23.59|6.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|23.59||||23.59|16.28|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.59||||23.59|6.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|23.59||||23.59|8.26|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.59||||23.59|6.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.59||||23.59|6.99|16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.59||||23.59||16.28|2.73
38063|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MYCOPHENOLATE SODIUM 360 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.59||||23.59||16.28|2.73
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|83.36||||83.36|36.76|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|83.36||||83.36|24.72|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|83.36||||83.36|39.18|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|83.36||||83.36|41.68|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|83.36||||83.36|41.68|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|83.36||||83.36|52.52|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|83.36||||83.36|24.72|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|83.36||||83.36|45.85|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|83.36||||83.36|57.52|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|83.36||||83.36|41.68|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|83.36||||83.36|36.76|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|83.36||||83.36|24.72|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|83.36||||83.36|36.76|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|83.36||||83.36|24.72|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|83.36||||83.36|24.72|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|83.36||||83.36|57.52|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|83.36||||83.36|24.72|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|Self-pay|Self-pay|83.36||||83.36|29.18|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|83.36||||83.36|24.72|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|83.36||||83.36|24.72|57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|83.36||||83.36||57.52|24.72
38100|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CINACALCET 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|83.36||||83.36||57.52|24.72
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AARP [1000]|AARP [100000]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|3.06||||3.06|1.35|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.06||||3.06|0.91|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.06||||3.06|1.44|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.06||||3.06|1.53|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.06||||3.06|1.53|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.06||||3.06|1.93|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.06||||3.06|0.91|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.06||||3.06|1.68|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.06||||3.06|2.11|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.06||||3.06|1.53|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.06||||3.06|1.35|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.06||||3.06|0.91|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.06||||3.06|1.35|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.06||||3.06|0.91|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.06||||3.06|0.91|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.06||||3.06|2.11|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.06||||3.06|0.91|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|Self-pay|Self-pay|3.06||||3.06|1.07|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.06||||3.06|0.91|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.06||||3.06|0.91|2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.06||||3.06||2.11|0.91
38213|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ORPHENADRINE CITRATE ER 100 MG TABLET,EXTENDED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.06||||3.06||2.11|0.91
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AARP [1000]|AARP [100000]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AETNA [1015]|AETNA [101529]|146.94||||146.94|64.8|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146.94||||146.94|43.57|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BCBS UTHCT [115568]|146.94||||146.94|69.06|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146.94||||146.94|73.47|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146.94||||146.94|73.47|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146.94||||146.94|92.57|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146.94||||146.94|43.57|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|CIGNA [1260]|CIGNA GWH [126023]|146.94||||146.94|80.82|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|146.94||||146.94|101.39|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|146.94||||146.94|73.47|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146.94||||146.94|64.8|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146.94||||146.94|43.57|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146.94||||146.94|64.8|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146.94||||146.94|43.57|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|146.94||||146.94|43.57|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|146.94||||146.94|101.39|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146.94||||146.94|43.57|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|Self-pay|Self-pay|146.94||||146.94|51.43|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|146.94||||146.94|43.57|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146.94||||146.94|43.57|101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146.94||||146.94||101.39|43.57
38263|ERX|0250 - PHARMACY-GENERAL|OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146.94||||146.94||101.39|43.57
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|AARP [1000]|AARP [100000]|1737.12||||1737.12|746.2|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1737.12||||1737.12|294.45|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|1737.12||||1737.12|829.68|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1737.12||||1737.12|515.06|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1737.12||||1737.12|291.53|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1737.12||||1737.12|291.53|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|1737.12||||1737.12|816.45|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1737.12||||1737.12|0|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1737.12||||1737.12|868.56|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1737.12||||1737.12|1094.39|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1737.12||||1737.12|515.06|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1737.12||||1737.12|291.53|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|1737.12||||1737.12|868.56|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1737.12||||1737.12|1198.61|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1737.12||||1737.12|38.95|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1737.12||||1737.12|291.53|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1737.12||||1737.12|829.68|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1737.12||||1737.12|515.06|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1737.12||||1737.12|291.53|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1737.12||||1737.12|829.68|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1737.12||||1737.12|515.06|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1737.12||||1737.12|515.06|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1737.12||||1737.12|1198.61|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1737.12||||1737.12|515.06|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|Self-pay|Self-pay|1737.12||||1737.12|607.99|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1737.12||||1737.12|515.06|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1737.12||||1737.12|515.06|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1737.12||||1737.12|746.2|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1737.12||||1737.12|291.53|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1737.12||||1737.12|291.53|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1737.12||||1737.12|746.2|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1737.12||||1737.12|291.53|1198.61|38.95
38270|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1737.12||||1737.12|583.06|1198.61|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|AARP [1000]|AARP [100000]|868.59||||868.59|373.1|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|868.59||||868.59|147.22|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|868.59||||868.59|414.84|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|868.59||||868.59|257.54|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|868.59||||868.59|145.77|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|868.59||||868.59|145.77|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|868.59||||868.59|408.24|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|868.59||||868.59|0|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|868.59||||868.59|434.3|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|868.59||||868.59|547.21|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|868.59||||868.59|257.54|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|868.59||||868.59|145.77|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|868.59||||868.59|434.3|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|868.59||||868.59|599.33|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|868.59||||868.59|38.95|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|868.59||||868.59|145.77|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|868.59||||868.59|414.84|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|868.59||||868.59|257.54|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|868.59||||868.59|145.77|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|868.59||||868.59|414.84|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|868.59||||868.59|257.54|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|868.59||||868.59|257.54|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|868.59||||868.59|599.33|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|868.59||||868.59|257.54|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|Self-pay|Self-pay|868.59||||868.59|304.01|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|868.59||||868.59|257.54|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|868.59||||868.59|257.54|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|868.59||||868.59|373.1|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|868.59||||868.59|145.77|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|868.59||||868.59|145.77|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|868.59||||868.59|373.1|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|868.59||||868.59|145.77|599.33|38.95
38271|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|868.59||||868.59|291.53|599.33|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|AARP [1000]|AARP [100000]|4541.5||||4541.5|1492.4|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4541.5||||4541.5|588.89|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|AETNA [1015]|AETNA [101529]|4541.5||||4541.5|1659.36|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4541.5||||4541.5|1346.55|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4541.5||||4541.5|583.06|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4541.5||||4541.5|583.06|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|BCBS [1155]|BCBS UTHCT [115568]|4541.5||||4541.5|2134.51|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4541.5||||4541.5|0|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4541.5||||4541.5|2270.75|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4541.5||||4541.5|2861.15|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4541.5||||4541.5|1346.55|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4541.5||||4541.5|583.06|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|CIGNA [1260]|CIGNA GWH [126023]|4541.5||||4541.5|2270.75|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|4541.5||||4541.5|3133.64|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4541.5||||4541.5|38.95|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4541.5||||4541.5|583.06|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4541.5||||4541.5|1659.36|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4541.5||||4541.5|1346.55|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4541.5||||4541.5|583.06|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4541.5||||4541.5|1659.36|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4541.5||||4541.5|1346.55|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|4541.5||||4541.5|1346.55|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|4541.5||||4541.5|3133.64|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4541.5||||4541.5|1346.55|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|Self-pay|Self-pay|4541.5||||4541.5|1589.52|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4541.5||||4541.5|1346.55|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4541.5||||4541.5|1346.55|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4541.5||||4541.5|1492.4|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4541.5||||4541.5|583.06|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4541.5||||4541.5|583.06|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4541.5||||4541.5|1492.4|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4541.5||||4541.5|583.06|3133.64|38.95
38280|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION|2,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4541.5||||4541.5|1166.12|3133.64|38.95
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AARP [1000]|AARP [100000]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AETNA [1015]|AETNA [101529]|4||||4|1.76|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4||||4|1.19|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BCBS UTHCT [115568]|4||||4|1.88|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4||||4|2|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4||||4|2|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4||||4|2.52|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4||||4|1.19|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|CIGNA [1260]|CIGNA GWH [126023]|4||||4|2.2|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4||||4|2.76|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4||||4|2|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4||||4|1.76|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4||||4|1.19|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4||||4|1.76|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4||||4|1.19|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4||||4|1.19|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4||||4|2.76|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4||||4|1.19|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|Self-pay|Self-pay|4||||4|1.4|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4||||4|1.19|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4||||4|1.19|2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4||||4||2.76|1.19
38285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 200 MG-200 MG-20 MG/5 ML ORAL SUSP|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4||||4||2.76|1.19
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|AARP [1000]|AARP [100000]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|581.25||||581.25|155.52|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|581.25||||581.25|172.34|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|581.25||||581.25|273.19|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|581.25||||581.25|0|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|581.25||||581.25|290.63|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|581.25||||581.25|366.19|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|581.25||||581.25|172.34|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|581.25||||581.25|290.63|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|581.25||||581.25|401.06|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|581.25||||581.25|1.18|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|581.25||||581.25|155.52|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|581.25||||581.25|172.34|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|581.25||||581.25|155.52|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|581.25||||581.25|172.34|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|581.25||||581.25|172.34|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|581.25||||581.25|401.06|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|581.25||||581.25|172.34|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|Self-pay|Self-pay|581.25||||581.25|203.44|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|581.25||||581.25|172.34|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|581.25||||581.25|172.34|401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|581.25||||581.25||401.06|1.18
38303|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|581.25||||581.25||401.06|1.18
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|AARP [1000]|AARP [100000]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|AETNA [1015]|AETNA [101529]|1.01||||1.01|0.45|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.01||||1.01|0.3|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|BCBS [1155]|BCBS UTHCT [115568]|1.01||||1.01|0.47|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.01||||1.01|0.51|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.01||||1.01|0.51|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.01||||1.01|0.64|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.01||||1.01|0.3|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|CIGNA [1260]|CIGNA GWH [126023]|1.01||||1.01|0.56|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|1.01||||1.01|0.7|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.01||||1.01|0.51|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.01||||1.01|0.45|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.01||||1.01|0.3|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.01||||1.01|0.45|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.01||||1.01|0.3|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.01||||1.01|0.3|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|1.01||||1.01|0.7|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.01||||1.01|0.3|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|Self-pay|Self-pay|1.01||||1.01|0.35|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.01||||1.01|0.3|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.01||||1.01|0.3|0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.01||||1.01||0.7|0.3
38321|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBOXYMETHYLCELLULOSE SODIUM 1 % EYE GEL IN A DROPPERETTE|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.01||||1.01||0.7|0.3
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.21||||0.21|0.09|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.21||||0.21|0.06|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.21||||0.21|0.1|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.21||||0.21|0.11|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.21||||0.21|0.11|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.21||||0.21|0.13|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.21||||0.21|0.06|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.21||||0.21|0.12|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.21||||0.21|0.14|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.21||||0.21|0.11|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.21||||0.21|0.09|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.21||||0.21|0.06|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.21||||0.21|0.09|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.21||||0.21|0.06|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.21||||0.21|0.06|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.21||||0.21|0.14|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.21||||0.21|0.06|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|Self-pay|Self-pay|0.21||||0.21|0.07|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.21||||0.21|0.06|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.21||||0.21|0.06|0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.21||||0.21||0.14|0.06
3841|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.21||||0.21||0.14|0.06
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|6.6||||6.6|2.91|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.6||||6.6|1.96|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|6.6||||6.6|3.1|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.6||||6.6|3.3|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.6||||6.6|3.3|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.6||||6.6|4.16|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.6||||6.6|1.96|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|6.6||||6.6|3.63|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.6||||6.6|4.55|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.6||||6.6|3.3|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.6||||6.6|2.91|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.6||||6.6|1.96|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.6||||6.6|2.91|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.6||||6.6|1.96|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.6||||6.6|1.96|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.6||||6.6|4.55|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.6||||6.6|1.96|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|Self-pay|Self-pay|6.6||||6.6|2.31|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.6||||6.6|1.96|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.6||||6.6|1.96|4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.6||||6.6||4.55|1.96
38421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MIRTAZAPINE 7.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.6||||6.6||4.55|1.96
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.39||||0.39|0.17|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.39||||0.39|0.12|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.39||||0.39|0.18|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.39||||0.39|0.2|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.39||||0.39|0.2|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.39||||0.39|0.25|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.39||||0.39|0.12|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.39||||0.39|0.21|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.39||||0.39|0.27|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.39||||0.39|0.2|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.39||||0.39|0.17|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.39||||0.39|0.12|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.39||||0.39|0.17|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.39||||0.39|0.12|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.39||||0.39|0.12|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.39||||0.39|0.27|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.39||||0.39|0.12|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|Self-pay|Self-pay|0.39||||0.39|0.14|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.39||||0.39|0.12|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.39||||0.39|0.12|0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.39||||0.39||0.27|0.12
3843|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.39||||0.39||0.27|0.12
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.35||||0.35|0.15|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.35||||0.35|0.1|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.35||||0.35|0.16|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.35||||0.35|0.18|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.35||||0.35|0.18|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.35||||0.35|0.22|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.35||||0.35|0.1|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.35||||0.35|0.19|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.35||||0.35|0.24|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.35||||0.35|0.18|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.35||||0.35|0.15|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.35||||0.35|0.1|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.35||||0.35|0.15|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.35||||0.35|0.1|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.35||||0.35|0.1|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.35||||0.35|0.24|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.35||||0.35|0.1|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|Self-pay|Self-pay|0.35||||0.35|0.12|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.35||||0.35|0.1|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.35||||0.35|0.1|0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.35||||0.35||0.24|0.1
3844|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IBUPROFEN 600 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.35||||0.35||0.24|0.1
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|7.44||||7.44|3.28|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.44||||7.44|2.21|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|7.44||||7.44|3.5|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.44||||7.44|3.72|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.44||||7.44|3.72|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.44||||7.44|4.69|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.44||||7.44|2.21|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|7.44||||7.44|4.09|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|7.44||||7.44|5.13|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.44||||7.44|3.72|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.44||||7.44|3.28|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.44||||7.44|2.21|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.44||||7.44|3.28|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.44||||7.44|2.21|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.44||||7.44|2.21|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|7.44||||7.44|5.13|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.44||||7.44|2.21|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|7.44||||7.44|2.6|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.44||||7.44|2.21|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.44||||7.44|2.21|5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.44||||7.44||5.13|2.21
38479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.44||||7.44||5.13|2.21
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|20.28||||20.28|8.94|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.28||||20.28|6.01|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|20.28||||20.28|9.53|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.28||||20.28|10.14|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.28||||20.28|10.14|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.28||||20.28|12.78|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.28||||20.28|6.01|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|20.28||||20.28|11.15|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|20.28||||20.28|13.99|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.28||||20.28|10.14|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.28||||20.28|8.94|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.28||||20.28|6.01|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.28||||20.28|8.94|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.28||||20.28|6.01|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.28||||20.28|6.01|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|20.28||||20.28|13.99|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.28||||20.28|6.01|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|20.28||||20.28|7.1|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.28||||20.28|6.01|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.28||||20.28|6.01|13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.28||||20.28||13.99|6.01
38480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 100 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.28||||20.28||13.99|6.01
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AARP [1000]|AARP [100000]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AARP [1000]|AARP [100000]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AETNA [1015]|AETNA [101529]|8.62||||8.62|3.8|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AETNA [1015]|AETNA [101529]|8.62||||8.62|3.8|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|8.62||||8.62|4.05|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|8.62||||8.62|4.05|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.62||||8.62|4.31|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.62||||8.62|4.31|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.62||||8.62|4.31|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.62||||8.62|4.31|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.62||||8.62|5.43|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.62||||8.62|5.43|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|8.62||||8.62|4.74|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|8.62||||8.62|4.74|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.62||||8.62|5.95|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.62||||8.62|5.95|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.62||||8.62|4.31|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.62||||8.62|4.31|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.62||||8.62|3.8|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.62||||8.62|3.8|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.62||||8.62|3.8|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.62||||8.62|3.8|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.62||||8.62|5.95|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.62||||8.62|5.95|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|Self-pay|Self-pay|8.62||||8.62|3.02|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|Self-pay|Self-pay|8.62||||8.62|3.02|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.62||||8.62|2.56|5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.62||||8.62||5.95|2.56
38488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUOXETINE 20 MG/5 ML (4 MG/ML) ORAL SOLUTION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.62||||8.62||5.95|2.56
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.75||||0.75|0.33|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.75||||0.75|0.22|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.75||||0.75|0.35|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.75||||0.75|0.38|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.75||||0.75|0.38|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.75||||0.75|0.47|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.75||||0.75|0.22|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.75||||0.75|0.41|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.75||||0.75|0.52|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.75||||0.75|0.38|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.75||||0.75|0.33|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.75||||0.75|0.22|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.75||||0.75|0.33|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.75||||0.75|0.22|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.75||||0.75|0.22|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.75||||0.75|0.52|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.75||||0.75|0.22|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.75||||0.75|0.26|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.75||||0.75|0.22|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.75||||0.75|0.22|0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.75||||0.75||0.52|0.22
3861|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IMIPRAMINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.75||||0.75||0.52|0.22
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AARP [1000]|AARP [100000]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AETNA [1015]|AETNA [101529]|141.27||||141.27|62.3|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|141.27||||141.27|41.89|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS [1155]|BCBS UTHCT [115568]|141.27||||141.27|66.4|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|141.27||||141.27|70.64|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|141.27||||141.27|70.64|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|141.27||||141.27|89|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|141.27||||141.27|41.89|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|CIGNA [1260]|CIGNA GWH [126023]|141.27||||141.27|77.7|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|141.27||||141.27|97.48|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|141.27||||141.27|70.64|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|141.27||||141.27|62.3|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|141.27||||141.27|41.89|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|141.27||||141.27|62.3|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|141.27||||141.27|41.89|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|141.27||||141.27|41.89|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|141.27||||141.27|97.48|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|141.27||||141.27|41.89|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|Self-pay|Self-pay|141.27||||141.27|49.44|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|141.27||||141.27|41.89|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|141.27||||141.27|41.89|97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|141.27||||141.27||97.48|41.89
38701|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACIN-POLYMYXN 3.5 MG-400 UNIT-10,000 UNIT/GRAM EYE OINT|3.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|141.27||||141.27||97.48|41.89
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|33.95||||33.95|8.93|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.95||||33.95|10.07|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|33.95||||33.95|15.96|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.95||||33.95|0|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.95||||33.95|16.98|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.95||||33.95|21.39|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.95||||33.95|10.07|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|33.95||||33.95|18.67|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33.95||||33.95|23.43|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.95||||33.95|0.69|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.95||||33.95|8.93|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.95||||33.95|10.07|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.95||||33.95|8.93|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.95||||33.95|10.07|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.95||||33.95|10.07|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33.95||||33.95|23.43|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.95||||33.95|10.07|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|33.95||||33.95|11.88|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.95||||33.95|10.07|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.95||||33.95|10.07|23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.95||||33.95||23.43|0.69
38703|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ADENOSINE 3 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.95||||33.95||23.43|0.69
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.6||||0.6|0.26|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.6||||0.6|0.18|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.6||||0.6|0.28|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.6||||0.6|0.3|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.6||||0.6|0.3|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.6||||0.6|0.38|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.6||||0.6|0.18|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.6||||0.6|0.33|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.6||||0.6|0.41|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.6||||0.6|0.3|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.6||||0.6|0.26|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.6||||0.6|0.18|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.6||||0.6|0.26|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.6||||0.6|0.18|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.6||||0.6|0.18|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.6||||0.6|0.41|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.6||||0.6|0.18|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.6||||0.6|0.21|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.6||||0.6|0.18|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.6||||0.6|0.18|0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.6||||0.6||0.41|0.18
3897|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|INDOMETHACIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.6||||0.6||0.41|0.18
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|AARP [1000]|AARP [100000]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|AETNA [1015]|AETNA [101529]|186||||186|82.03|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|186||||186|55.15|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|BCBS [1155]|BCBS UTHCT [115568]|186||||186|87.42|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|186||||186|93|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|186||||186|93|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|186||||186|117.18|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|186||||186|55.15|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|CIGNA [1260]|CIGNA GWH [126023]|186||||186|102.3|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|186||||186|128.34|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|186||||186|99.81|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|186||||186|82.03|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|186||||186|55.15|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|186||||186|82.03|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|186||||186|55.15|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|186||||186|55.15|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|186||||186|128.34|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|186||||186|55.15|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|Self-pay|Self-pay|186||||186|65.1|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|186||||186|55.15|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|186||||186|55.15|128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|186||||186||128.34|55.15
39009012|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC CRYOPRECIPITATE 1 UNIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|186||||186||128.34|55.15
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AARP [1000]|AARP [100000]|934||||934|420.3|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|934||||934|190.4|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AETNA [1015]|AETNA [101529]|934||||934|411.89|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|934||||934|276.93|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|934||||934|188.51|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|934||||934|188.51|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BCBS UTHCT [115568]|934||||934|438.98|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|934||||934|467|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|934||||934|467|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|934||||934|588.42|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|934||||934|276.93|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|934||||934|188.51|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|CIGNA [1260]|CIGNA GWH [126023]|934||||934|513.7|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|934||||934|644.46|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|934||||934|235.64|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|934||||934|201.9|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|934||||934|411.89|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|934||||934|276.93|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|934||||934|188.51|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|934||||934|411.89|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|934||||934|276.93|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|934||||934|276.93|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|934||||934|644.46|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|934||||934|276.93|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|Self-pay|Self-pay|934||||934|326.9|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|934||||934|276.93|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|934||||934|276.93|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|934||||934|420.3|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|934||||934|188.51|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|934||||934|188.51|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|934||||934|420.3|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|934||||934|188.51|644.46|188.51
39009016|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC REDCELLS LEUKO POOR 1 UNIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|934||||934|377.02|644.46|188.51
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|AARP [1000]|AARP [100000]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|AETNA [1015]|AETNA [101529]|295||||295|130.1|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|295||||295|87.47|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|BCBS [1155]|BCBS UTHCT [115568]|295||||295|138.65|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|295||||295|147.5|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|295||||295|147.5|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|295||||295|185.85|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|295||||295|87.47|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|CIGNA [1260]|CIGNA GWH [126023]|295||||295|162.25|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|295||||295|203.55|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|295||||295|103.33|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|295||||295|130.1|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|295||||295|87.47|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|295||||295|130.1|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|295||||295|87.47|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|295||||295|87.47|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|295||||295|203.55|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|295||||295|87.47|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|Self-pay|Self-pay|295||||295|103.25|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|295||||295|87.47|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|295||||295|87.47|203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|295||||295||203.55|87.47
39009017|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN PER UNIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|295||||295||203.55|87.47
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AARP [1000]|AARP [100000]|1994||||1994|897.3|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1994||||1994|491.66|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AETNA [1015]|AETNA [101529]|1994||||1994|879.35|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1994||||1994|591.22|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1994||||1994|486.8|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1994||||1994|486.8|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS [1155]|BCBS UTHCT [115568]|1994||||1994|937.18|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1994||||1994|997|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1994||||1994|997|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1994||||1994|1256.22|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1994||||1994|591.22|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1994||||1994|486.8|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|CIGNA [1260]|CIGNA GWH [126023]|1994||||1994|1096.7|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1994||||1994|1375.86|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1994||||1994|608.5|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1994||||1994|521.36|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1994||||1994|879.35|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1994||||1994|591.22|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1994||||1994|486.8|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1994||||1994|879.35|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1994||||1994|591.22|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1994||||1994|591.22|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1994||||1994|1375.86|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1994||||1994|591.22|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|Self-pay|Self-pay|1994||||1994|697.9|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1994||||1994|591.22|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1994||||1994|362.5|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1994||||1994|897.3|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1994||||1994|486.8|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1994||||1994|486.8|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1994||||1994|897.3|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1994||||1994|486.8|1375.86|362.5
39009035|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELETS LEUKOPOOR PHERESIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1994||||1994|973.59|1375.86|362.5
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|AARP [1000]|AARP [100000]|2346||||2346|1055.7|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2346||||2346|623.51|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|AETNA [1015]|AETNA [101529]|2346||||2346|1034.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2346||||2346|695.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2346||||2346|617.33|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2346||||2346|617.33|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|BCBS [1155]|BCBS UTHCT [115568]|2346||||2346|1102.62|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2346||||2346|1173|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2346||||2346|1173|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2346||||2346|1477.98|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2346||||2346|695.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2346||||2346|617.33|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|CIGNA [1260]|CIGNA GWH [126023]|2346||||2346|1290.3|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2346||||2346|1618.74|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2346||||2346|771.66|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2346||||2346|661.17|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2346||||2346|1034.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2346||||2346|695.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2346||||2346|617.33|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2346||||2346|1034.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2346||||2346|695.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2346||||2346|695.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2346||||2346|1618.74|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2346||||2346|695.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|Self-pay|Self-pay|2346||||2346|821.1|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2346||||2346|695.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2346||||2346|566.59|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2346||||2346|1055.7|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2346||||2346|617.33|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2346||||2346|617.33|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2346||||2346|1055.7|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2346||||2346|617.33|1618.74|566.59
39009037|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLATELET PHERESIS L/R IRR EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2346||||2346|1234.67|1618.74|566.59
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AARP [1000]|AARP [100000]|964||||964|433.8|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|964||||964|263.15|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AETNA [1015]|AETNA [101529]|964||||964|425.12|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|964||||964|285.83|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|964||||964|260.55|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|964||||964|260.55|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BCBS UTHCT [115568]|964||||964|453.08|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|964||||964|482|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|964||||964|482|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|964||||964|607.32|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|964||||964|285.83|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|964||||964|260.55|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|CIGNA [1260]|CIGNA GWH [126023]|964||||964|530.2|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|964||||964|665.16|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|964||||964|325.69|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|964||||964|279.04|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|964||||964|425.12|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|964||||964|285.83|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|964||||964|260.55|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|964||||964|425.12|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|964||||964|285.83|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|964||||964|285.83|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|964||||964|665.16|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|964||||964|285.83|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|Self-pay|Self-pay|964||||964|337.4|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|964||||964|285.83|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|964||||964|153|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|964||||964|433.8|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|964||||964|260.55|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|964||||964|260.55|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|964||||964|433.8|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|964||||964|260.55|665.16|153
39009040|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC RBC L/R IRRADIATED EACH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|964||||964|521.09|665.16|153
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AARP [1000]|AARP [100000]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AETNA [1015]|AETNA [101529]|214||||214|94.37|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|63.45|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BCBS UTHCT [115568]|214||||214|100.58|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|107|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|107|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|134.82|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|63.45|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|CIGNA [1260]|CIGNA GWH [126023]|214||||214|117.7|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214||||214|88.94|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|94.37|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|63.45|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|94.37|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|63.45|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214||||214|63.45|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|63.45|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|Self-pay|Self-pay|214||||214|74.9|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214||||214|63.45|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|51|147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214||147.66|51
39009059|EAP|0390 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC PLASMA FROZEN 8-24 HOURS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214||147.66|51
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.7||||0.7|0.31|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.7||||0.7|0.21|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.7||||0.7|0.33|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.7||||0.7|0.35|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.7||||0.7|0.35|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.7||||0.7|0.44|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.7||||0.7|0.21|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.7||||0.7|0.39|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.7||||0.7|0.48|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.7||||0.7|0.35|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.7||||0.7|0.31|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.7||||0.7|0.21|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.7||||0.7|0.31|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.7||||0.7|0.21|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.7||||0.7|0.21|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.7||||0.7|0.48|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.7||||0.7|0.21|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.7||||0.7|0.24|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.7||||0.7|0.21|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.7||||0.7|0.21|0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.7||||0.7||0.48|0.21
391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMILORIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.7||||0.7||0.48|0.21
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AARP [1000]|AARP [100000]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AETNA [1015]|AETNA [101529]|60.13||||60.13|26.52|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|60.13||||60.13|17.83|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS [1155]|BCBS UTHCT [115568]|60.13||||60.13|28.26|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|60.13||||60.13|30.07|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|60.13||||60.13|30.07|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|60.13||||60.13|37.88|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|60.13||||60.13|17.83|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|CIGNA [1260]|CIGNA GWH [126023]|60.13||||60.13|33.07|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|60.13||||60.13|41.49|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|60.13||||60.13|30.07|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|60.13||||60.13|26.52|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|60.13||||60.13|17.83|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|60.13||||60.13|26.52|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|60.13||||60.13|17.83|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|60.13||||60.13|17.83|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|60.13||||60.13|41.49|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|60.13||||60.13|17.83|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|Self-pay|Self-pay|60.13||||60.13|21.05|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|60.13||||60.13|17.83|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|60.13||||60.13|17.83|41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|60.13||||60.13||41.49|17.83
39136|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL POWDER|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|60.13||||60.13||41.49|17.83
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AARP [1000]|AARP [100000]|1370.23||||1370.23|616.6|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1370.23||||1370.23|363.66|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AETNA [1015]|AETNA [101529]|1370.23||||1370.23|604.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1370.23||||1370.23|406.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1370.23||||1370.23|360.06|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1370.23||||1370.23|360.06|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BCBS UTHCT [115568]|1370.23||||1370.23|644.01|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1370.23||||1370.23|685.12|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1370.23||||1370.23|685.12|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1370.23||||1370.23|863.24|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1370.23||||1370.23|406.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1370.23||||1370.23|360.06|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|CIGNA [1260]|CIGNA GWH [126023]|1370.23||||1370.23|575|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1370.23||||1370.23|945.46|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1370.23||||1370.23|496.33|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1370.23||||1370.23|385.63|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1370.23||||1370.23|604.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1370.23||||1370.23|406.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1370.23||||1370.23|360.06|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1370.23||||1370.23|604.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1370.23||||1370.23|406.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1370.23||||1370.23|406.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1370.23||||1370.23|945.46|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1370.23||||1370.23|406.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|Self-pay|Self-pay|1370.23||||1370.23|479.58|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1370.23||||1370.23|406.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1370.23||||1370.23|406.27|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1370.23||||1370.23|616.6|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1370.23||||1370.23|360.06|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1370.23||||1370.23|360.06|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1370.23||||1370.23|616.6|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1370.23||||1370.23|360.06|945.46|360.06
39136430|EAP|0391 - ADMINISTRATION, PROCESSING AND STORAGE FOR|HC TRANSFUSN BLD/BLD COMPONTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1370.23||||1370.23|720.13|945.46|360.06
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|190.37||||190.37|83.95|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|190.37||||190.37|56.44|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|190.37||||190.37|89.47|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|190.37||||190.37|95.19|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|190.37||||190.37|95.19|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|190.37||||190.37|119.93|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|190.37||||190.37|56.44|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|190.37||||190.37|104.7|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|190.37||||190.37|131.36|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|190.37||||190.37|95.19|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|190.37||||190.37|83.95|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|190.37||||190.37|56.44|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|190.37||||190.37|83.95|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|190.37||||190.37|56.44|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|190.37||||190.37|56.44|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|190.37||||190.37|131.36|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|190.37||||190.37|56.44|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|Self-pay|Self-pay|190.37||||190.37|66.63|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|190.37||||190.37|56.44|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|190.37||||190.37|56.44|131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|190.37||||190.37||131.36|56.44
39255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|EMTRICITABINE 200 MG-TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|190.37||||190.37||131.36|56.44
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|AARP [1000]|AARP [100000]|102.26||||102.26|102.26|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102.26||||102.26||102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|AETNA [1015]|AETNA [101529]|102.26||||102.26|61.78|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102.26||||102.26|30.32|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102.26||||102.26||102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102.26||||102.26||102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|BCBS [1155]|BCBS UTHCT [115568]|102.26||||102.26|48.06|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102.26||||102.26|0|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102.26||||102.26|51.13|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102.26||||102.26|64.42|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102.26||||102.26|30.32|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102.26||||102.26||102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|CIGNA [1260]|CIGNA GWH [126023]|102.26||||102.26|56.24|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|102.26||||102.26|70.56|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102.26||||102.26|3.35|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102.26||||102.26||102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102.26||||102.26|61.78|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102.26||||102.26|30.32|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102.26||||102.26||102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102.26||||102.26|61.78|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102.26||||102.26|30.32|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|102.26||||102.26|30.32|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|102.26||||102.26|70.56|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102.26||||102.26|30.32|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|Self-pay|Self-pay|102.26||||102.26|35.79|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102.26||||102.26|30.32|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102.26||||102.26|30.32|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102.26||||102.26|102.26|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102.26||||102.26||102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102.26||||102.26||102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102.26||||102.26|102.26|102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102.26||||102.26||102.26|3.35
39265|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION|45 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102.26||||102.26||102.26|3.35
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|AARP [1000]|AARP [100000]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|4.96||||4.96|2.19|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.96||||4.96|1.47|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|4.96||||4.96|2.33|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.96||||4.96|2.48|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.96||||4.96|2.48|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.96||||4.96|3.12|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.96||||4.96|1.47|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|4.96||||4.96|2.73|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.96||||4.96|3.42|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.96||||4.96|2.48|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.96||||4.96|2.19|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.96||||4.96|1.47|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.96||||4.96|2.19|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.96||||4.96|1.47|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.96||||4.96|1.47|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.96||||4.96|3.42|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.96||||4.96|1.47|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|Self-pay|Self-pay|4.96||||4.96|1.74|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.96||||4.96|1.47|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.96||||4.96|1.47|3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.96||||4.96||3.42|1.47
39277|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DULOXETINE 60 MG CAPSULE,DELAYED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.96||||4.96||3.42|1.47
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|AARP [1000]|AARP [100000]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|AETNA [1015]|AETNA [101529]|18.83||||18.83|8.3|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.83||||18.83|5.58|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|18.83||||18.83|8.85|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.83||||18.83|9.42|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.83||||18.83|9.42|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.83||||18.83|11.86|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.83||||18.83|5.58|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|18.83||||18.83|10.36|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|18.83||||18.83|12.99|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.83||||18.83|9.42|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.83||||18.83|8.3|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.83||||18.83|5.58|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.83||||18.83|8.3|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.83||||18.83|5.58|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.83||||18.83|5.58|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|18.83||||18.83|12.99|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.83||||18.83|5.58|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|Self-pay|Self-pay|18.83||||18.83|6.59|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.83||||18.83|5.58|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.83||||18.83|5.58|12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.83||||18.83||12.99|5.58
39575|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE CR 500 MG CAPSULE,CONTROLLED RELEASE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.83||||18.83||12.99|5.58
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|20.15||||20.15|8.89|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.15||||20.15|5.97|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|20.15||||20.15|9.47|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.15||||20.15|10.08|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.15||||20.15|10.08|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.15||||20.15|12.69|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.15||||20.15|5.97|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|20.15||||20.15|11.08|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|20.15||||20.15|13.9|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.15||||20.15|10.08|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.15||||20.15|8.89|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.15||||20.15|5.97|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.15||||20.15|8.89|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.15||||20.15|5.97|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.15||||20.15|5.97|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|20.15||||20.15|13.9|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.15||||20.15|5.97|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|20.15||||20.15|7.05|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.15||||20.15|5.97|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.15||||20.15|5.97|13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.15||||20.15||13.9|5.97
39744|ERX|0250 - PHARMACY-GENERAL|FLUMAZENIL 0.1 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.15||||20.15||13.9|5.97
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|7.58||||7.58|7.58|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.58||||7.58|2.25|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|7.58||||7.58|3.56|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.58||||7.58|0|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.58||||7.58|3.79|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.58||||7.58|4.78|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.58||||7.58|2.25|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|7.58||||7.58|4.17|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.58||||7.58|5.23|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.58||||7.58|5.75|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.58||||7.58|7.58|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.58||||7.58|2.25|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.58||||7.58|7.58|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.58||||7.58|2.25|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.58||||7.58|2.25|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.58||||7.58|5.23|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.58||||7.58|2.25|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|7.58||||7.58|2.65|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.58||||7.58|2.25|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.58||||7.58|2.25|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.58||||7.58||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|66.5||||66.5|66.5|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66.5||||66.5|19.72|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|66.5||||66.5|31.26|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66.5||||66.5|0|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66.5||||66.5|33.25|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66.5||||66.5|41.9|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66.5||||66.5|19.72|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|66.5||||66.5|36.58|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|66.5||||66.5|45.89|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66.5||||66.5|5.75|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66.5||||66.5|66.5|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66.5||||66.5|19.72|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66.5||||66.5|66.5|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66.5||||66.5|19.72|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|66.5||||66.5|19.72|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|66.5||||66.5|45.89|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66.5||||66.5|19.72|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|Self-pay|Self-pay|66.5||||66.5|23.27|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66.5||||66.5|19.72|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66.5||||66.5|19.72|66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66.5||||66.5||66.5|2.25
39918|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TOBRAMYCIN 40 MG/ML INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66.5||||66.5||66.5|2.25
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|AARP [1000]|AARP [100000]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|34.26||||34.26|15.11|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.26||||34.26|10.16|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|34.26||||34.26|16.1|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.26||||34.26|17.13|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.26||||34.26|17.13|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.26||||34.26|21.58|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.26||||34.26|10.16|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|34.26||||34.26|18.84|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|34.26||||34.26|23.64|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34.26||||34.26|17.13|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.26||||34.26|15.11|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.26||||34.26|10.16|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.26||||34.26|15.11|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.26||||34.26|10.16|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|34.26||||34.26|10.16|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|34.26||||34.26|23.64|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.26||||34.26|10.16|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|Self-pay|Self-pay|34.26||||34.26|11.99|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34.26||||34.26|10.16|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.26||||34.26|10.16|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.26||||34.26||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|AARP [1000]|AARP [100000]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|346.27||||346.27|152.71|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|346.27||||346.27|102.67|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|346.27||||346.27|162.75|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|346.27||||346.27|173.14|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|346.27||||346.27|173.14|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|346.27||||346.27|218.15|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|346.27||||346.27|102.67|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|346.27||||346.27|190.45|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|346.27||||346.27|238.93|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|346.27||||346.27|173.14|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|346.27||||346.27|152.71|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|346.27||||346.27|102.67|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|346.27||||346.27|152.71|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|346.27||||346.27|102.67|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|346.27||||346.27|102.67|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|346.27||||346.27|238.93|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|346.27||||346.27|102.67|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|Self-pay|Self-pay|346.27||||346.27|121.19|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|346.27||||346.27|102.67|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|346.27||||346.27|102.67|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|346.27||||346.27||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|AARP [1000]|AARP [100000]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|AETNA [1015]|AETNA [101529]|1644.24||||1644.24|725.11|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1644.24||||1644.24|487.52|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|BCBS [1155]|BCBS UTHCT [115568]|1644.24||||1644.24|772.79|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1644.24||||1644.24|822.12|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1644.24||||1644.24|822.12|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1644.24||||1644.24|1035.87|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1644.24||||1644.24|487.52|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|CIGNA [1260]|CIGNA GWH [126023]|1644.24||||1644.24|904.33|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1644.24||||1644.24|1134.53|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1644.24||||1644.24|822.12|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1644.24||||1644.24|725.11|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1644.24||||1644.24|487.52|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1644.24||||1644.24|725.11|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1644.24||||1644.24|487.52|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1644.24||||1644.24|487.52|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1644.24||||1644.24|1134.53|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1644.24||||1644.24|487.52|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|Self-pay|Self-pay|1644.24||||1644.24|575.48|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1644.24||||1644.24|487.52|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1644.24||||1644.24|487.52|1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1644.24||||1644.24||1134.53|10.16
39970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION|480 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1644.24||||1644.24||1134.53|10.16
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.11||||1.11|0.49|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.11||||1.11|0.33|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.11||||1.11|0.52|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.11||||1.11|0.56|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.11||||1.11|0.56|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.11||||1.11|0.7|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.11||||1.11|0.33|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.11||||1.11|0.61|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.11||||1.11|0.77|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.11||||1.11|0.56|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.11||||1.11|0.49|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.11||||1.11|0.33|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.11||||1.11|0.49|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.11||||1.11|0.33|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.11||||1.11|0.33|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.11||||1.11|0.77|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.11||||1.11|0.33|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|Self-pay|Self-pay|1.11||||1.11|0.39|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.11||||1.11|0.33|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.11||||1.11|0.33|0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.11||||1.11||0.77|0.33
40009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 48 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.11||||1.11||0.77|0.33
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.02||||2.02|0.89|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.02||||2.02|0.6|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.02||||2.02|0.95|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.02||||2.02|1.01|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.02||||2.02|1.01|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.02||||2.02|1.27|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.02||||2.02|0.6|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.02||||2.02|1.11|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.02||||2.02|1.39|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.02||||2.02|1.01|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.02||||2.02|0.89|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.02||||2.02|0.6|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.02||||2.02|0.89|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.02||||2.02|0.6|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.02||||2.02|0.6|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.02||||2.02|1.39|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.02||||2.02|0.6|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|Self-pay|Self-pay|2.02||||2.02|0.71|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.02||||2.02|0.6|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.02||||2.02|0.6|1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.02||||2.02||1.39|0.6
40010|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENOFIBRATE NANOCRYSTALLIZED 145 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.02||||2.02||1.39|0.6
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AARP [1000]|AARP [100000]|7.75||||7.75|3.49|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.75||||7.75||5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AETNA [1015]|AETNA [101529]|7.75||||7.75|1.54|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.75||||7.75|2.3|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.75||||7.75||5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.75||||7.75||5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BCBS UTHCT [115568]|7.75||||7.75|3.64|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.75||||7.75|0|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.75||||7.75|3.88|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.75||||7.75|4.88|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.75||||7.75|2.3|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.75||||7.75||5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|CIGNA [1260]|CIGNA GWH [126023]|7.75||||7.75|4.26|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.75||||7.75|5.35|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.75||||7.75|0.85|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.75||||7.75||5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.75||||7.75|1.54|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.75||||7.75|2.3|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.75||||7.75||5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.75||||7.75|1.54|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.75||||7.75|2.3|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.75||||7.75|2.3|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.75||||7.75|5.35|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.75||||7.75|2.3|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|Self-pay|Self-pay|7.75||||7.75|2.71|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.75||||7.75|2.3|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.75||||7.75|2.3|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.75||||7.75|3.49|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.75||||7.75||5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.75||||7.75||5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.75||||7.75|3.49|5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.75||||7.75||5.35|0.85
400291|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.9 % IV BOLUS|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.75||||7.75||5.35|0.85
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5|6.98|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|6.12|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|3.41|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|6.12|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|6.12|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5|6.98|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5|6.98|10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|3.41
400292|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % IV BOLUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|3.41
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|8.42|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|4.91|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|8.42|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|8.42|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|4.6
400293|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IV BOLUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|4.6
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5|6.98|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|5.62|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|3.11|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|5.62|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|5.62|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5|6.98|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5|6.98|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|AARP [1000]|AARP [100000]|12.4||||12.4|5.58|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.4||||12.4||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|AETNA [1015]|AETNA [101529]|12.4||||12.4|5.62|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.4||||12.4|3.68|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.4||||12.4||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.4||||12.4||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|BCBS [1155]|BCBS UTHCT [115568]|12.4||||12.4|5.83|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.4||||12.4|0|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.4||||12.4|6.2|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.4||||12.4|7.81|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.4||||12.4|3.68|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.4||||12.4||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|CIGNA [1260]|CIGNA GWH [126023]|12.4||||12.4|6.82|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.4||||12.4|8.56|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.4||||12.4|3.11|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.4||||12.4||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.4||||12.4|5.62|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.4||||12.4|3.68|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.4||||12.4||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.4||||12.4|5.62|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.4||||12.4|3.68|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.4||||12.4|3.68|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.4||||12.4|8.56|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.4||||12.4|3.68|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|Self-pay|Self-pay|12.4||||12.4|4.34|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.4||||12.4|3.68|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.4||||12.4|3.68|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.4||||12.4|5.58|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.4||||12.4||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.4||||12.4||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.4||||12.4|5.58|10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.4||||12.4||10.7|3.11
400296|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS IV BOLUS|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.4||||12.4||10.7|3.11
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|AARP [1000]|AARP [100000]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|AETNA [1015]|AETNA [101529]|0.19||||0.19|0.08|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.19||||0.19|0.06|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|BCBS [1155]|BCBS UTHCT [115568]|0.19||||0.19|0.09|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.19||||0.19|0.1|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.19||||0.19|0.1|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.19||||0.19|0.12|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.19||||0.19|0.06|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|CIGNA [1260]|CIGNA GWH [126023]|0.19||||0.19|0.1|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.19||||0.19|0.13|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.19||||0.19|0.1|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.19||||0.19|0.08|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.19||||0.19|0.06|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.19||||0.19|0.08|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.19||||0.19|0.06|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.19||||0.19|0.06|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.19||||0.19|0.13|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.19||||0.19|0.06|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|Self-pay|Self-pay|0.19||||0.19|0.07|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.19||||0.19|0.06|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.19||||0.19|0.06|0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.19||||0.19||0.13|0.06
400499|ERX|0250 - PHARMACY-GENERAL|MAGIC MOUTHWASH ORAL SUSPENSION AHS STANDARD SIMPLE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.19||||0.19||0.13|0.06
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|0.15||||0.15|0.07|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.15||||0.15|0.04|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.15||||0.15|0.07|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.15||||0.15|0.08|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.15||||0.15|0.08|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.15||||0.15|0.09|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.15||||0.15|0.04|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.15||||0.15|0.08|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.15||||0.15|0.1|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.15||||0.15|0.08|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.15||||0.15|0.07|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.15||||0.15|0.04|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.15||||0.15|0.07|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.15||||0.15|0.04|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.15||||0.15|0.04|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.15||||0.15|0.1|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.15||||0.15|0.04|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|Self-pay|Self-pay|0.15||||0.15|0.05|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.15||||0.15|0.04|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.15||||0.15|0.04|0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.15||||0.15||0.1|0.04
400503|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 12.5 MG PO SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.15||||0.15||0.1|0.04
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|AARP [1000]|AARP [100000]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|AETNA [1015]|AETNA [101529]|0.72||||0.72|0.32|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.72||||0.72|0.21|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.72||||0.72|0.34|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.72||||0.72|0.36|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.72||||0.72|0.36|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.72||||0.72|0.45|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.72||||0.72|0.21|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.72||||0.72|0.4|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.72||||0.72|0.5|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.72||||0.72|0.36|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.72||||0.72|0.32|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.72||||0.72|0.21|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.72||||0.72|0.32|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.72||||0.72|0.21|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.72||||0.72|0.21|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.72||||0.72|0.5|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.72||||0.72|0.21|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|Self-pay|Self-pay|0.72||||0.72|0.25|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.72||||0.72|0.21|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.72||||0.72|0.21|0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.72||||0.72||0.5|0.21
400954|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 12.5 MG PO SPLIT TABLET|2 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.72||||0.72||0.5|0.21
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|0.15||||0.15|0.07|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.15||||0.15|0.04|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.15||||0.15|0.07|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.15||||0.15|0.08|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.15||||0.15|0.08|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.15||||0.15|0.09|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.15||||0.15|0.04|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.15||||0.15|0.08|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.15||||0.15|0.1|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.15||||0.15|0.08|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.15||||0.15|0.07|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.15||||0.15|0.04|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.15||||0.15|0.07|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.15||||0.15|0.04|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.15||||0.15|0.04|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.15||||0.15|0.1|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.15||||0.15|0.04|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|Self-pay|Self-pay|0.15||||0.15|0.05|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.15||||0.15|0.04|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.15||||0.15|0.04|0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.15||||0.15||0.1|0.04
400957|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 12.5 MG PO SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.15||||0.15||0.1|0.04
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|AARP [1000]|AARP [100000]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|AETNA [1015]|AETNA [101529]|2.14||||2.14|0.94|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.14||||2.14|0.63|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|BCBS [1155]|BCBS UTHCT [115568]|2.14||||2.14|1.01|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.14||||2.14|1.07|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.14||||2.14|1.07|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.14||||2.14|1.35|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.14||||2.14|0.63|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|CIGNA [1260]|CIGNA GWH [126023]|2.14||||2.14|1.18|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.14||||2.14|1.48|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.14||||2.14|1.07|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.14||||2.14|0.94|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.14||||2.14|0.63|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.14||||2.14|0.94|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.14||||2.14|0.63|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.14||||2.14|0.63|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.14||||2.14|1.48|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.14||||2.14|0.63|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|Self-pay|Self-pay|2.14||||2.14|0.75|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.14||||2.14|0.63|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.14||||2.14|0.63|1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.14||||2.14||1.48|0.63
400958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL SUCCINATE ER 12.5 MG TABLET,EXTENDED RELEASE 24 HR SPLIT TABLET|2 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.14||||2.14||1.48|0.63
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|AARP [1000]|AARP [100000]|82||||82|80|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82||||82||82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|AETNA [1015]|AETNA [101529]|82||||82|82|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82||||82|51.79|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82||||82||82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82||||82||82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|BCBS [1155]|BCBS UTHCT [115568]|82||||82|38.54|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|82||||82|31.09|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|82||||82|41|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|82||||82|51.66|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|82||||82|51.79|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82||||82||82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|CIGNA [1260]|CIGNA GWH [126023]|82||||82|45.1|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|82||||82|56.58|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|82||||82|41|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82||||82||82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82||||82|82|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82||||82|51.79|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82||||82||82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82||||82|82|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82||||82|51.79|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|82||||82|51.79|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|82||||82|56.58|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82||||82|51.79|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|Self-pay|Self-pay|82||||82|28.7|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|82||||82|51.79|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|82||||82|51.79|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82||||82|80|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|82||||82||82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|82||||82||82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82||||82|80|82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82||||82||82|28.7
40177061|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO UNILATERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|82||||82||82|28.7
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|AARP [1000]|AARP [100000]|82||||82|80|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82||||82|24.57|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|AETNA [1015]|AETNA [101529]|82||||82|82|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82||||82|51.79|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82||||82|24.33|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82||||82|24.33|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|BCBS [1155]|BCBS UTHCT [115568]|82||||82|38.54|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|82||||82|31.09|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|82||||82|41|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|82||||82|51.66|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|82||||82|51.79|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82||||82|24.33|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|CIGNA [1260]|CIGNA GWH [126023]|82||||82|45.1|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|82||||82|56.58|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|82||||82|41|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82||||82|24.33|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82||||82|82|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82||||82|51.79|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82||||82|24.33|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82||||82|82|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82||||82|51.79|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|82||||82|51.79|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|82||||82|56.58|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82||||82|51.79|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|Self-pay|Self-pay|82||||82|28.7|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|82||||82|51.79|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|82||||82|51.79|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82||||82|80|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|82||||82|24.33|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|82||||82|24.33|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82||||82|80|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82||||82|24.33|82|24.33
40177062|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO DIG TOMO BILATERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|82||||82||82|24.33
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|AARP [1000]|AARP [100000]|438||||438|80|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|438||||438|88.05|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|AETNA [1015]|AETNA [101529]|438||||438|145.63|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|438||||438|129.87|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|438||||438|87.18|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|438||||438|87.18|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|BCBS [1155]|BCBS UTHCT [115568]|438||||438|205.86|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|438||||438|116.9|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|438||||438|219|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|438||||438|275.94|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|438||||438|129.87|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|438||||438|87.18|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|CIGNA [1260]|CIGNA GWH [126023]|438||||438|240.9|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|438||||438|302.22|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|438||||438|108.98|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|438||||438|87.18|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|438||||438|145.63|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|438||||438|129.87|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|438||||438|87.18|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|438||||438|145.63|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|438||||438|129.87|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|438||||438|129.87|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|438||||438|302.22|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|438||||438|129.87|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|Self-pay|Self-pay|438||||438|153.3|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|438||||438|129.87|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|438||||438|129.87|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|438||||438|80|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|438||||438|87.18|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|438||||438|87.18|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|438||||438|80|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|438||||438|87.18|302.22|80
40177065|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD UNILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|438||||438|174.36|302.22|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AARP [1000]|AARP [100000]|545||||545|80|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|545||||545|112.62|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AETNA [1015]|AETNA [101529]|545||||545|185.71|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|545||||545|161.59|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|545||||545|111.5|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|545||||545|111.5|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|545||||545|256.15|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|545||||545|149.3|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|545||||545|272.5|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|545||||545|343.35|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|545||||545|161.59|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|545||||545|111.5|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|545||||545|299.75|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|545||||545|376.05|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|545||||545|139.38|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|545||||545|111.5|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|545||||545|185.71|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|545||||545|161.59|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|545||||545|111.5|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|545||||545|185.71|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|545||||545|161.59|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|545||||545|161.59|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|545||||545|376.05|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|545||||545|161.59|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|Self-pay|Self-pay|545||||545|190.75|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|545||||545|161.59|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|545||||545|161.59|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|545||||545|80|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|545||||545|111.5|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|545||||545|111.5|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|545||||545|80|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|545||||545|111.5|376.05|80
40177066|EAP|0401 - OTHER IMAGING SERVICES-DIAGNOSTIC MAMMOGRAP|HC DIAG MAMMO W/ CAD BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|545||||545|223|376.05|80
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|AARP [1000]|AARP [100000]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|904.71||||904.71|398.98|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|904.71||||904.71|268.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|BCBS [1155]|BCBS UTHCT [115568]|904.71||||904.71|425.21|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|904.71||||904.71|452.36|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|904.71||||904.71|452.36|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|904.71||||904.71|569.97|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|904.71||||904.71|268.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|CIGNA [1260]|CIGNA GWH [126023]|904.71||||904.71|497.59|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|904.71||||904.71|624.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|904.71||||904.71|452.36|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|904.71||||904.71|398.98|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|904.71||||904.71|268.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|904.71||||904.71|398.98|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|904.71||||904.71|268.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|904.71||||904.71|268.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|904.71||||904.71|624.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|904.71||||904.71|268.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|Self-pay|Self-pay|904.71||||904.71|316.65|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|904.71||||904.71|268.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|904.71||||904.71|268.25|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|904.71||||904.71||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|9.57||||9.57|4.22|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.57||||9.57|2.84|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|9.57||||9.57|4.5|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.57||||9.57|4.79|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.57||||9.57|4.79|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.57||||9.57|6.03|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.57||||9.57|2.84|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|9.57||||9.57|5.26|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.57||||9.57|6.6|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.57||||9.57|4.79|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.57||||9.57|4.22|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.57||||9.57|2.84|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.57||||9.57|4.22|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.57||||9.57|2.84|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.57||||9.57|2.84|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.57||||9.57|6.6|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.57||||9.57|2.84|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|Self-pay|Self-pay|9.57||||9.57|3.35|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.57||||9.57|2.84|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.57||||9.57|2.84|624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.57||||9.57||624.25|2.84
4025|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 50 MG/5 ML ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.57||||9.57||624.25|2.84
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.37||||0.37|0.16|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.37||||0.37|0.11|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.37||||0.37|0.17|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.37||||0.37|0.19|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.37||||0.37|0.19|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.37||||0.37|0.23|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.37||||0.37|0.11|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.37||||0.37|0.2|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.37||||0.37|0.26|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.37||||0.37|0.19|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.37||||0.37|0.16|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.37||||0.37|0.11|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.37||||0.37|0.16|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.37||||0.37|0.11|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.37||||0.37|0.11|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.37||||0.37|0.26|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.37||||0.37|0.11|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|Self-pay|Self-pay|0.37||||0.37|0.13|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.37||||0.37|0.11|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.37||||0.37|0.11|0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.37||||0.37||0.26|0.11
4026|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISONIAZID 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.37||||0.37||0.26|0.11
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|AARP [1000]|AARP [100000]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|AETNA [1015]|AETNA [101529]|411||||411|130.03|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|411||||411|111.6|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|BCBS [1155]|BCBS UTHCT [115568]|411||||411|193.17|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|411||||411|139.64|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|411||||411|205.5|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|411||||411|258.93|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|411||||411|111.6|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|CIGNA [1260]|CIGNA GWH [126023]|411||||411|155.72|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|411||||411|283.59|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|411||||411|136.21|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|411||||411|130.03|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|411||||411|111.6|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|411||||411|130.03|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|411||||411|111.6|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|411||||411|111.6|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|411||||411|283.59|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|411||||411|111.6|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|Self-pay|Self-pay|411||||411|143.85|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|411||||411|111.6|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|411||||411|111.6|283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|411||||411||283.59|111.6
40276506|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ENCEPHALOGRAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|411||||411||283.59|111.6
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AARP [1000]|AARP [100000]|848||||848|250|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|848||||848|99.8|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AETNA [1015]|AETNA [101529]|848||||848|137.28|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|848||||848|110.94|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|848||||848|98.82|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|848||||848|98.82|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS [1155]|BCBS UTHCT [115568]|848||||848|398.56|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|848||||848|139.64|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|848||||848|424|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|848||||848|534.24|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|848||||848|110.94|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|848||||848|98.82|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|CIGNA [1260]|CIGNA GWH [126023]|848||||848|146.54|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|848||||848|585.12|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|848||||848|136.21|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|848||||848|105.83|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|848||||848|137.28|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|848||||848|110.94|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|848||||848|98.82|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|848||||848|137.28|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|848||||848|110.94|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|848||||848|110.94|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|848||||848|585.12|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|848||||848|110.94|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|Self-pay|Self-pay|848||||848|296.8|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|848||||848|110.94|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|848||||848|110.94|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|848||||848|250|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|848||||848|98.82|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|848||||848|98.82|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|848||||848|250|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|848||||848|98.82|585.12|98.82
40276536|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SOFT TISSUE HEAD/NECK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|848||||848|197.63|585.12|98.82
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|AARP [1000]|AARP [100000]|825||||825|250|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|825||||825|99.8|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|AETNA [1015]|AETNA [101529]|825||||825|78.29|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|825||||825|84.88|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|825||||825|98.82|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|825||||825|98.82|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|BCBS [1155]|BCBS UTHCT [115568]|825||||825|387.75|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|825||||825|139.64|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|825||||825|412.5|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|825||||825|519.75|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|825||||825|84.88|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|825||||825|98.82|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|CIGNA [1260]|CIGNA GWH [126023]|825||||825|119.64|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|825||||825|569.25|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|825||||825|136.21|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|825||||825|105.83|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|825||||825|78.29|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|825||||825|84.88|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|825||||825|98.82|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|825||||825|78.29|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|825||||825|84.88|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|825||||825|84.88|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|825||||825|569.25|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|825||||825|84.88|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|Self-pay|Self-pay|825||||825|288.75|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|825||||825|84.88|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|825||||825|84.88|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|825||||825|250|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|825||||825|98.82|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|825||||825|98.82|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|825||||825|250|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|825||||825|98.82|569.25|78.29
40276604|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC US CHEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|825||||825|197.63|569.25|78.29
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AARP [1000]|AARP [100000]|747||||747|250|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|747||||747|99.8|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AETNA [1015]|AETNA [101529]|747||||747|110.57|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|747||||747|102.25|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|747||||747|98.82|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|747||||747|98.82|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS [1155]|BCBS UTHCT [115568]|747||||747|351.09|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|747||||747|139.64|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|747||||747|373.5|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|747||||747|470.61|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|747||||747|102.25|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|747||||747|98.82|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|CIGNA [1260]|CIGNA GWH [126023]|747||||747|410.85|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|747||||747|515.43|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|747||||747|136.21|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|747||||747|105.83|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|747||||747|110.57|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|747||||747|102.25|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|747||||747|98.82|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|747||||747|110.57|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|747||||747|102.25|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|747||||747|102.25|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|747||||747|515.43|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|747||||747|102.25|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|Self-pay|Self-pay|747||||747|261.45|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|747||||747|102.25|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|747||||747|102.25|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|747||||747|250|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|747||||747|98.82|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|747||||747|98.82|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|747||||747|250|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|747||||747|98.82|515.43|98.82
40276641|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST COMPLETE UNILATERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|747||||747|197.63|515.43|98.82
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|AARP [1000]|AARP [100000]|747||||747|250|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|747||||747|74.1|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|AETNA [1015]|AETNA [101529]|747||||747|83.86|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|747||||747|62.12|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|747||||747|73.36|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|747||||747|73.36|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|BCBS [1155]|BCBS UTHCT [115568]|747||||747|351.09|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|747||||747|75.79|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|747||||747|373.5|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|747||||747|470.61|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|747||||747|62.12|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|747||||747|73.36|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|CIGNA [1260]|CIGNA GWH [126023]|747||||747|410.85|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|747||||747|515.43|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|747||||747|101.13|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|747||||747|78.57|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|747||||747|83.86|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|747||||747|62.12|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|747||||747|73.36|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|747||||747|83.86|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|747||||747|62.12|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|747||||747|62.12|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|747||||747|515.43|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|747||||747|62.12|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|Self-pay|Self-pay|747||||747|261.45|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|747||||747|62.12|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|747||||747|62.12|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|747||||747|250|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|747||||747|73.36|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|747||||747|73.36|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|747||||747|250|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|747||||747|73.36|515.43|62.12
40276642|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC BREAST LIMITED UNILATERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|747||||747|146.73|515.43|62.12
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|AARP [1000]|AARP [100000]|1497||||1497|250|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1497||||1497|99.8|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|AETNA [1015]|AETNA [101529]|1497||||1497|128.38|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1497||||1497|114.46|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1497||||1497|98.82|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1497||||1497|98.82|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|1497||||1497|703.59|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1497||||1497|139.64|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1497||||1497|748.5|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1497||||1497|943.11|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1497||||1497|114.46|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1497||||1497|98.82|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|1497||||1497|187.3|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1497||||1497|1032.93|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1497||||1497|136.21|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1497||||1497|105.83|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1497||||1497|128.38|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1497||||1497|114.46|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1497||||1497|98.82|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1497||||1497|128.38|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1497||||1497|114.46|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1497||||1497|114.46|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1497||||1497|1032.93|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1497||||1497|114.46|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|Self-pay|Self-pay|1497||||1497|523.95|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1497||||1497|114.46|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1497||||1497|114.46|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1497||||1497|250|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1497||||1497|98.82|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1497||||1497|98.82|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1497||||1497|250|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1497||||1497|98.82|1032.93|98.82
40276700|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1497||||1497|197.63|1032.93|98.82
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AARP [1000]|AARP [100000]|1118||||1118|250|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1118||||1118|99.8|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AETNA [1015]|AETNA [101529]|1118||||1118|96.65|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1118||||1118|87.21|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1118||||1118|98.82|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1118||||1118|98.82|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|1118||||1118|525.46|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1118||||1118|139.64|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1118||||1118|559|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1118||||1118|704.34|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1118||||1118|87.21|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1118||||1118|98.82|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|1118||||1118|140.09|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1118||||1118|771.42|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1118||||1118|136.21|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1118||||1118|105.83|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1118||||1118|96.65|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1118||||1118|87.21|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1118||||1118|98.82|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1118||||1118|96.65|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1118||||1118|87.21|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1118||||1118|87.21|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1118||||1118|771.42|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1118||||1118|87.21|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|Self-pay|Self-pay|1118||||1118|391.3|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1118||||1118|87.21|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1118||||1118|87.21|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1118||||1118|250|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1118||||1118|98.82|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1118||||1118|98.82|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1118||||1118|250|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1118||||1118|98.82|771.42|87.21
40276705|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC ABDOMEN LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1118||||1118|197.63|771.42|87.21
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|AARP [1000]|AARP [100000]|455||||455|250|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|455||||455|99.8|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|AETNA [1015]|AETNA [101529]|455||||455|135.05|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|455||||455|88.68|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|455||||455|98.82|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|455||||455|98.82|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|BCBS [1155]|BCBS UTHCT [115568]|455||||455|213.85|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|455||||455|83.19|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|455||||455|227.5|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|455||||455|286.65|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|455||||455|88.68|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|455||||455|98.82|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|CIGNA [1260]|CIGNA GWH [126023]|455||||455|250.25|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|455||||455|313.95|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|455||||455|136.21|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|455||||455|105.83|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|455||||455|135.05|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|455||||455|88.68|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|455||||455|98.82|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|455||||455|135.05|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|455||||455|88.68|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|455||||455|88.68|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|455||||455|313.95|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|455||||455|88.68|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|Self-pay|Self-pay|455||||455|159.25|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|455||||455|88.68|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|455||||455|88.68|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|455||||455|250|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|455||||455|98.82|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|455||||455|98.82|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|455||||455|250|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|455||||455|98.82|313.95|83.19
40276706|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC AORTA/AAA SCREENING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|455||||455|197.63|313.95|83.19
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AARP [1000]|AARP [100000]|1160||||1160|250|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1160||||1160|99.8|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AETNA [1015]|AETNA [101529]|1160||||1160|119.47|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1160||||1160|107.93|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1160||||1160|98.82|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1160||||1160|98.82|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|1160||||1160|545.2|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1160||||1160|139.64|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1160||||1160|580|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1160||||1160|730.8|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1160||||1160|107.93|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1160||||1160|98.82|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|1160||||1160|180.35|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1160||||1160|800.4|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1160||||1160|136.21|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1160||||1160|105.83|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1160||||1160|119.47|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1160||||1160|107.93|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1160||||1160|98.82|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1160||||1160|119.47|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1160||||1160|107.93|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1160||||1160|107.93|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1160||||1160|800.4|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1160||||1160|107.93|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|Self-pay|Self-pay|1160||||1160|406|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1160||||1160|107.93|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1160||||1160|107.93|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1160||||1160|250|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1160||||1160|98.82|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1160||||1160|98.82|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1160||||1160|250|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1160||||1160|98.82|800.4|98.82
40276770|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1160||||1160|197.63|800.4|98.82
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|AARP [1000]|AARP [100000]|1001||||1001|250|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1001||||1001|99.8|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|AETNA [1015]|AETNA [101529]|1001||||1001|46.56|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1001||||1001|55.14|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1001||||1001|98.82|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1001||||1001|98.82|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|1001||||1001|470.47|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1001||||1001|139.64|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1001||||1001|500.5|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1001||||1001|630.63|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1001||||1001|55.14|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1001||||1001|98.82|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|1001||||1001|141.17|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1001||||1001|690.69|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1001||||1001|136.21|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1001||||1001|105.83|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1001||||1001|46.56|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1001||||1001|55.14|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1001||||1001|98.82|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1001||||1001|46.56|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1001||||1001|55.14|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1001||||1001|55.14|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1001||||1001|690.69|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1001||||1001|55.14|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|Self-pay|Self-pay|1001||||1001|350.35|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1001||||1001|55.14|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1001||||1001|55.14|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1001||||1001|250|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1001||||1001|98.82|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1001||||1001|98.82|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1001||||1001|250|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1001||||1001|98.82|690.69|46.56
40276775|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC RETROPERITIONEAL LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1001||||1001|197.63|690.69|46.56
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|AARP [1000]|AARP [100000]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|AETNA [1015]|AETNA [101529]|405||||405|132.26|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|405||||405|114.46|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|BCBS [1155]|BCBS UTHCT [115568]|405||||405|190.35|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|405||||405|139.64|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|405||||405|202.5|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|405||||405|255.15|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|405||||405|114.46|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|CIGNA [1260]|CIGNA GWH [126023]|405||||405|169.13|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|405||||405|279.45|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|405||||405|136.21|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|405||||405|132.26|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|405||||405|114.46|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|405||||405|132.26|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|405||||405|114.46|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|405||||405|114.46|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|405||||405|279.45|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|405||||405|114.46|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|Self-pay|Self-pay|405||||405|141.75|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|405||||405|114.46|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|405||||405|114.46|279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|405||||405||279.45|114.46
40276800|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SPINAL CANAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|405||||405||279.45|114.46
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|AARP [1000]|AARP [100000]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|AETNA [1015]|AETNA [101529]|1122||||1122|113.35|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1122||||1122|114.46|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|BCBS [1155]|BCBS UTHCT [115568]|1122||||1122|527.34|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1122||||1122|91.95|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1122||||1122|561|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1122||||1122|706.86|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1122||||1122|114.46|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|CIGNA [1260]|CIGNA GWH [126023]|1122||||1122|186.58|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1122||||1122|774.18|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1122||||1122|136.21|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1122||||1122|113.35|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1122||||1122|114.46|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1122||||1122|113.35|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1122||||1122|114.46|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1122||||1122|114.46|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1122||||1122|774.18|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1122||||1122|114.46|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|Self-pay|Self-pay|1122||||1122|392.7|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1122||||1122|114.46|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1122||||1122|114.46|774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1122||||1122||774.18|91.95
40276801|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY <14WKS TRANSABDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1122||||1122||774.18|91.95
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|AARP [1000]|AARP [100000]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|AETNA [1015]|AETNA [101529]|1158||||1158|141.17|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1158||||1158|114.46|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|BCBS [1155]|BCBS UTHCT [115568]|1158||||1158|544.26|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1158||||1158|114.72|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1158||||1158|579|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1158||||1158|729.54|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1158||||1158|114.46|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|CIGNA [1260]|CIGNA GWH [126023]|1158||||1158|202.19|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1158||||1158|799.02|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1158||||1158|136.21|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1158||||1158|141.17|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1158||||1158|114.46|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1158||||1158|141.17|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1158||||1158|114.46|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1158||||1158|114.46|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1158||||1158|799.02|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1158||||1158|114.46|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|Self-pay|Self-pay|1158||||1158|405.3|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1158||||1158|114.46|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1158||||1158|114.46|799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1158||||1158||799.02|114.46
40276805|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY >=14WKS TRANSABDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1158||||1158||799.02|114.46
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|AARP [1000]|AARP [100000]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|AETNA [1015]|AETNA [101529]|347||||347|80.5|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|347||||347|80.53|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|347||||347|163.09|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|347||||347|139.64|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|347||||347|173.5|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|347||||347|218.61|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|347||||347|80.53|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|347||||347|128.71|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|347||||347|239.43|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|347||||347|136.21|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|347||||347|80.5|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|347||||347|80.53|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|347||||347|80.5|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|347||||347|80.53|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|347||||347|80.53|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|347||||347|239.43|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|347||||347|80.53|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|Self-pay|Self-pay|347||||347|121.45|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|347||||347|80.53|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|347||||347|80.53|239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|347||||347||239.43|80.5
40276815|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|347||||347||239.43|80.5
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|AARP [1000]|AARP [100000]|1467||||1467|250|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1467||||1467|99.8|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|AETNA [1015]|AETNA [101529]|1467||||1467|91.08|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1467||||1467|92.55|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1467||||1467|98.82|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1467||||1467|98.82|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|BCBS [1155]|BCBS UTHCT [115568]|1467||||1467|689.49|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1467||||1467|139.64|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1467||||1467|733.5|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1467||||1467|924.21|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1467||||1467|92.55|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1467||||1467|98.82|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|CIGNA [1260]|CIGNA GWH [126023]|1467||||1467|141.47|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1467||||1467|1012.23|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1467||||1467|136.21|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1467||||1467|105.83|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1467||||1467|91.08|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1467||||1467|92.55|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1467||||1467|98.82|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1467||||1467|91.08|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1467||||1467|92.55|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1467||||1467|92.55|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1467||||1467|1012.23|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1467||||1467|92.55|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|Self-pay|Self-pay|1467||||1467|513.45|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1467||||1467|92.55|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1467||||1467|92.55|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1467||||1467|250|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1467||||1467|98.82|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1467||||1467|98.82|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1467||||1467|250|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1467||||1467|98.82|1012.23|91.08
40276817|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PREGNANCY TRANSVAGINAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1467||||1467|197.63|1012.23|91.08
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|AARP [1000]|AARP [100000]|1262||||1262|250|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1262||||1262|99.8|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|AETNA [1015]|AETNA [101529]|1262||||1262|138.38|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1262||||1262|114.46|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1262||||1262|98.82|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1262||||1262|98.82|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|BCBS [1155]|BCBS UTHCT [115568]|1262||||1262|593.14|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1262||||1262|109.02|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1262||||1262|631|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1262||||1262|795.06|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1262||||1262|114.46|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1262||||1262|98.82|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|CIGNA [1260]|CIGNA GWH [126023]|1262||||1262|161|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1262||||1262|870.78|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1262||||1262|136.21|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1262||||1262|105.83|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1262||||1262|138.38|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1262||||1262|114.46|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1262||||1262|98.82|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1262||||1262|138.38|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1262||||1262|114.46|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1262||||1262|114.46|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1262||||1262|870.78|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1262||||1262|114.46|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|Self-pay|Self-pay|1262||||1262|441.7|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1262||||1262|114.46|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1262||||1262|114.46|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1262||||1262|250|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1262||||1262|98.82|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1262||||1262|98.82|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1262||||1262|250|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1262||||1262|98.82|870.78|98.82
40276830|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSVAGINAL SONO NON OB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1262||||1262|197.63|870.78|98.82
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|AARP [1000]|AARP [100000]|1220||||1220|250|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1220||||1220|99.8|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|AETNA [1015]|AETNA [101529]|1220||||1220|117.79|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1220||||1220|96.28|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1220||||1220|98.82|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1220||||1220|98.82|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|1220||||1220|573.4|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1220||||1220|139.64|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1220||||1220|610|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1220||||1220|768.6|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1220||||1220|96.28|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1220||||1220|98.82|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|1220||||1220|161.54|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1220||||1220|841.8|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1220||||1220|136.21|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1220||||1220|105.83|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1220||||1220|117.79|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1220||||1220|96.28|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1220||||1220|98.82|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1220||||1220|117.79|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1220||||1220|96.28|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1220||||1220|96.28|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1220||||1220|841.8|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1220||||1220|96.28|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|Self-pay|Self-pay|1220||||1220|427|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1220||||1220|96.28|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1220||||1220|96.28|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1220||||1220|250|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1220||||1220|98.82|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1220||||1220|98.82|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1220||||1220|250|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1220||||1220|98.82|841.8|96.28
40276856|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1220||||1220|197.63|841.8|96.28
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|AARP [1000]|AARP [100000]|269||||269|250|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|269||||269|99.8|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|AETNA [1015]|AETNA [101529]|269||||269|37.1|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|269||||269|50.79|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|269||||269|98.82|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|269||||269|98.82|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|BCBS [1155]|BCBS UTHCT [115568]|269||||269|126.43|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|269||||269|139.64|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|269||||269|134.5|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|269||||269|169.47|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|269||||269|50.79|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|269||||269|98.82|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|CIGNA [1260]|CIGNA GWH [126023]|269||||269|138.1|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|269||||269|185.61|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|269||||269|136.21|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|269||||269|105.83|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|269||||269|37.1|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|269||||269|50.79|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|269||||269|98.82|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|269||||269|37.1|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|269||||269|50.79|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|269||||269|50.79|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|269||||269|185.61|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|269||||269|50.79|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|Self-pay|Self-pay|269||||269|94.15|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|269||||269|50.79|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|269||||269|50.79|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|269||||269|250|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|269||||269|98.82|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|269||||269|98.82|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|269||||269|250|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|269||||269|98.82|250|37.1
40276857|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC PELVIS NON OB LIMITED/FOLLOW-UP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|269||||269|197.63|250|37.1
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AARP [1000]|AARP [100000]|978||||978|250|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|978||||978|99.8|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AETNA [1015]|AETNA [101529]|978||||978|114.46|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|978||||978|64.49|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|978||||978|98.82|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|978||||978|98.82|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS [1155]|BCBS UTHCT [115568]|978||||978|459.66|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|978||||978|139.64|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|978||||978|489|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|978||||978|616.14|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|978||||978|64.49|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|978||||978|98.82|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|CIGNA [1260]|CIGNA GWH [126023]|978||||978|159.46|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|978||||978|674.82|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|978||||978|136.21|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|978||||978|105.83|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|978||||978|114.46|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|978||||978|64.49|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|978||||978|98.82|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|978||||978|114.46|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|978||||978|64.49|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|978||||978|64.49|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|978||||978|674.82|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|978||||978|64.49|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|Self-pay|Self-pay|978||||978|342.3|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|978||||978|64.49|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|978||||978|64.49|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|978||||978|250|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|978||||978|98.82|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|978||||978|98.82|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|978||||978|250|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|978||||978|98.82|674.82|64.49
40276870|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC SCROTUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|978||||978|197.63|674.82|64.49
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|AARP [1000]|AARP [100000]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|AETNA [1015]|AETNA [101529]|986||||986|172.9|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|986||||986|91.89|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|BCBS [1155]|BCBS UTHCT [115568]|986||||986|463.42|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|986||||986|78.37|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|986||||986|493|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|986||||986|621.18|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|986||||986|91.89|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|CIGNA [1260]|CIGNA GWH [126023]|986||||986|191.71|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|986||||986|680.34|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|986||||986|136.21|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|986||||986|172.9|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|986||||986|91.89|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|986||||986|172.9|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|986||||986|91.89|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|986||||986|91.89|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|986||||986|680.34|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|986||||986|91.89|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|Self-pay|Self-pay|986||||986|345.1|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|986||||986|91.89|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|986||||986|91.89|680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|986||||986||680.34|78.37
40276872|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC TRANSRECTAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|986||||986||680.34|78.37
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|AARP [1000]|AARP [100000]|423||||423|250|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|423||||423|99.8|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|AETNA [1015]|AETNA [101529]|423||||423|51|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|423||||423|30.35|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|423||||423|98.82|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|423||||423|98.82|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|423||||423|198.81|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|423||||423|139.64|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|423||||423|211.5|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|423||||423|266.49|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|423||||423|30.35|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|423||||423|98.82|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|423||||423|232.65|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|423||||423|291.87|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|423||||423|136.21|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|423||||423|105.83|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|423||||423|51|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|423||||423|30.35|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|423||||423|98.82|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|423||||423|51|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|423||||423|30.35|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|423||||423|30.35|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|423||||423|291.87|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|423||||423|30.35|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|Self-pay|Self-pay|423||||423|148.05|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|423||||423|30.35|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|423||||423|30.35|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|423||||423|250|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|423||||423|98.82|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|423||||423|98.82|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|423||||423|250|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|423||||423|98.82|291.87|30.35
40276882|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC EXTREMITY NONVASC LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|423||||423|197.63|291.87|30.35
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|AARP [1000]|AARP [100000]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|AETNA [1015]|AETNA [101529]|235||||235|122.81|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|235||||235|62.12|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|BCBS [1155]|BCBS UTHCT [115568]|235||||235|110.45|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|235||||235|75.79|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|235||||235|117.5|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|235||||235|148.05|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|235||||235|62.12|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|CIGNA [1260]|CIGNA GWH [126023]|235||||235|176.03|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|235||||235|162.15|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|235||||235|101.13|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|235||||235|122.81|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|235||||235|62.12|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|235||||235|122.81|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|235||||235|62.12|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|235||||235|62.12|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|235||||235|162.15|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|235||||235|62.12|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|Self-pay|Self-pay|235||||235|82.25|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|235||||235|62.12|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|235||||235|62.12|176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|235||||235||176.03|62.12
40276885|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC HIPS INFANT DYNAMIC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|235||||235||176.03|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|AARP [1000]|AARP [100000]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|AETNA [1015]|AETNA [101529]|618||||618|116.14|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|618||||618|62.12|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|618||||618|290.46|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|618||||618|75.79|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|618||||618|309|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|618||||618|389.34|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|618||||618|62.12|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|618||||618|140.04|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|618||||618|426.42|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|618||||618|101.13|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|618||||618|116.14|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|618||||618|62.12|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|618||||618|116.14|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|618||||618|62.12|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|618||||618|62.12|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|618||||618|426.42|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|618||||618|62.12|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|Self-pay|Self-pay|618||||618|216.3|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|618||||618|62.12|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|618||||618|62.12|426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|618||||618||426.42|62.12
40276886|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC INFANT HIPS, STATIC/LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|618||||618||426.42|62.12
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|AARP [1000]|AARP [100000]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|AETNA [1015]|AETNA [101529]|918||||918|269.54|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|918||||918|248.83|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|BCBS [1155]|BCBS UTHCT [115568]|918||||918|431.46|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|918||||918|217.17|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|918||||918|459|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|918||||918|578.34|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|918||||918|248.83|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|CIGNA [1260]|CIGNA GWH [126023]|918||||918|470.9|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|918||||918|633.42|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|918||||918|330.56|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|918||||918|269.54|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|918||||918|248.83|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|918||||918|269.54|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|918||||918|248.83|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|918||||918|248.83|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|918||||918|633.42|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|918||||918|248.83|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|Self-pay|Self-pay|918||||918|321.3|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|918||||918|248.83|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|918||||918|248.83|633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|918||||918||633.42|217.17
40276936|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC COMP REP AV FIST/PSUEDO-ANEUR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|918||||918||633.42|217.17
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|AARP [1000]|AARP [100000]|962||||962|250|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|962||||962||663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|AETNA [1015]|AETNA [101529]|962||||962|39.89|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|962||||962|285.23|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|962||||962||663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|962||||962||663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|BCBS [1155]|BCBS UTHCT [115568]|962||||962|452.14|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|962||||962|34.15|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|962||||962|481|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|962||||962|606.06|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|962||||962|285.23|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|962||||962||663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|CIGNA [1260]|CIGNA GWH [126023]|962||||962|248.76|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|962||||962|663.78|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|962||||962|481|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|962||||962||663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|962||||962|39.89|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|962||||962|285.23|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|962||||962||663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|962||||962|39.89|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|962||||962|285.23|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|962||||962|285.23|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|962||||962|663.78|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|962||||962|285.23|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|Self-pay|Self-pay|962||||962|336.7|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|962||||962|285.23|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|962||||962|285.23|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|962||||962|250|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|962||||962||663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|962||||962||663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|962||||962|250|663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|962||||962||663.78|34.15
40276942|EAP|0402 - OTHER IMAGING SERVICES-ULTRASOUND|HC GUIDANCE NEEDLE PLCMT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|962||||962||663.78|34.15
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|49.34||||49.34|21.76|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49.34||||49.34|14.63|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|49.34||||49.34|23.19|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49.34||||49.34|24.67|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49.34||||49.34|24.67|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49.34||||49.34|31.08|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49.34||||49.34|14.63|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|49.34||||49.34|27.14|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|49.34||||49.34|34.04|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|49.34||||49.34|24.67|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49.34||||49.34|21.76|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49.34||||49.34|14.63|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49.34||||49.34|21.76|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49.34||||49.34|14.63|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|49.34||||49.34|14.63|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|49.34||||49.34|34.04|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49.34||||49.34|14.63|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|49.34||||49.34|17.27|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|49.34||||49.34|14.63|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49.34||||49.34|14.63|34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49.34||||49.34||34.04|14.63
40369|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MESALAMINE 1,000 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49.34||||49.34||34.04|14.63
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|AARP [1000]|AARP [100000]|82||||82|80|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82||||82|24.57|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|AETNA [1015]|AETNA [101529]|82||||82|38.95|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82||||82|51.79|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82||||82|24.33|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82||||82|24.33|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|BCBS [1155]|BCBS UTHCT [115568]|82||||82|38.54|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|82||||82|31.09|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|82||||82|41|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|82||||82|51.66|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|82||||82|51.79|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82||||82|24.33|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|CIGNA [1260]|CIGNA GWH [126023]|82||||82|45.1|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|82||||82|56.58|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|82||||82|30.41|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82||||82|24.33|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82||||82|38.95|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82||||82|51.79|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82||||82|24.33|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82||||82|38.95|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82||||82|51.79|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|82||||82|51.79|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|82||||82|56.58|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82||||82|51.79|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|Self-pay|Self-pay|82||||82|28.7|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|82||||82|51.79|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|82||||82|51.79|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82||||82|80|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|82||||82|24.33|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|82||||82|24.33|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82||||82|80|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82||||82|24.33|80|24.33
40377063|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING DIG TOMO/3-D BREAST BILATERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|82||||82|48.66|80|24.33
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|AARP [1000]|AARP [100000]|483||||483|80|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|483||||483|93.1|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|AETNA [1015]|AETNA [101529]|483||||483|153.98|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|483||||483|143.21|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|483||||483|92.18|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|483||||483|92.18|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|483||||483|227.01|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|483||||483|123.48|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|483||||483|241.5|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|483||||483|304.29|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|483||||483|143.21|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|483||||483|92.18|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|483||||483|265.65|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|483||||483|333.27|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|483||||483|115.23|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|483||||483|92.18|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|483||||483|153.98|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|483||||483|143.21|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|483||||483|92.18|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|483||||483|153.98|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|483||||483|143.21|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|483||||483|143.21|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|483||||483|333.27|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|483||||483|143.21|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|Self-pay|Self-pay|483||||483|169.05|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|483||||483|143.21|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|483||||483|143.21|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|483||||483|80|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|483||||483|92.18|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|483||||483|92.18|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|483||||483|80|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|483||||483|92.18|333.27|80
40377067|EAP|0403 - OTHER IMAGING SERVICES-SCREENING MAMMOGRAPH|HC SCREENING MAMMO W/CAD BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|483||||483|184.36|333.27|80
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401001|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401002|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401003|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401004|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401007|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401008|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401009|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401010|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401011|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401012|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401013|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401014|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401015|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401016|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401017|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401018|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401019|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401020|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401021|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401022|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
40401023|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|AARP [1000]|AARP [100000]|4687.27||||4687.27|1489|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4687.27||||4687.27|1421.78|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|AETNA [1015]|AETNA [101529]|4687.27||||4687.27|3184.8|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4687.27||||4687.27|1389.78|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4687.27||||4687.27|1407.7|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4687.27||||4687.27|1407.7|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|4687.27||||4687.27|2203.02|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4687.27||||4687.27|0|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4687.27||||4687.27|2343.64|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4687.27||||4687.27|2952.98|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4687.27||||4687.27|1389.78|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4687.27||||4687.27|1407.7|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|4687.27||||4687.27|2343.64|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|4687.27||||4687.27|3234.22|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4687.27||||4687.27|16.79|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4687.27||||4687.27|1407.7|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4687.27||||4687.27|3184.8|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4687.27||||4687.27|1389.78|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4687.27||||4687.27|1407.7|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4687.27||||4687.27|3184.8|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4687.27||||4687.27|1389.78|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|4687.27||||4687.27|1389.78|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|4687.27||||4687.27|3234.22|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4687.27||||4687.27|1389.78|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|Self-pay|Self-pay|4687.27||||4687.27|1640.54|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4687.27||||4687.27|1389.78|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4687.27||||4687.27|1389.78|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4687.27||||4687.27|1489|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4687.27||||4687.27|1407.7|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4687.27||||4687.27|1407.7|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4687.27||||4687.27|1489|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4687.27||||4687.27|1407.7|3234.22|16.79
40475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PACLITAXEL-PROTEIN BOUND 100 MG INTRAVENOUS SUSPENSION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4687.27||||4687.27|2815.4|3234.22|16.79
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|AARP [1000]|AARP [100000]|6402||||6402|2800|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6402||||6402|1355.82|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|AETNA [1015]|AETNA [101529]|6402||||6402|2148|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6402||||6402|1321.53|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6402||||6402|1342.4|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6402||||6402|1342.4|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|BCBS [1155]|BCBS UTHCT [115568]|6402||||6402|1650|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6402||||6402|1674.74|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6402||||6402|2200|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6402||||6402|2200|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6402||||6402|1321.53|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6402||||6402|1342.4|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|CIGNA [1260]|CIGNA GWH [126023]|6402||||6402|2800|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6402||||6402|4417.38|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6402||||6402|1850.43|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6402||||6402|1437.71|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6402||||6402|2148|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6402||||6402|1321.53|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6402||||6402|1342.4|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6402||||6402|2148|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6402||||6402|1321.53|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6402||||6402|1321.53|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6402||||6402|4417.38|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6402||||6402|1321.53|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|Self-pay|Self-pay|6402||||6402|2240.7|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6402||||6402|1321.53|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6402||||6402|1321.53|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6402||||6402|2800|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6402||||6402|1342.4|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6402||||6402|1342.4|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6402||||6402|2800|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6402||||6402|1342.4|4417.38|1321.53
40478815|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC CT FUSN IMAGE SKUL TO THGH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6402||||6402|2684.8|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|AARP [1000]|AARP [100000]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|AETNA [1015]|AETNA [101529]|6402||||6402|2148|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6402||||6402|1321.53|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|BCBS [1155]|BCBS UTHCT [115568]|6402||||6402|1650|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6402||||6402|1674.74|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6402||||6402|2200|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6402||||6402|2200|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6402||||6402|1321.53|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|CIGNA [1260]|CIGNA GWH [126023]|6402||||6402|2800|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|6402||||6402|4417.38|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6402||||6402|1850.43|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6402||||6402|2148|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6402||||6402|1321.53|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6402||||6402|2148|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6402||||6402|1321.53|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|6402||||6402|1321.53|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|6402||||6402|4417.38|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6402||||6402|1321.53|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|Self-pay|Self-pay|6402||||6402|2240.7|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6402||||6402|1321.53|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6402||||6402|1321.53|4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6402||||6402||4417.38|1321.53
40478816|EAP|0404 - OTHER IMAGING SERVICES-POSITRON EMISSION TO|HC PET/CT IMAGING WHOLE BODY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6402||||6402||4417.38|1321.53
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.89||||2.89|1.27|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.89||||2.89|0.86|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.89||||2.89|1.36|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.89||||2.89|1.45|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.89||||2.89|1.45|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.89||||2.89|1.82|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.89||||2.89|0.86|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.89||||2.89|1.59|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.89||||2.89|1.99|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.89||||2.89|1.45|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.89||||2.89|1.27|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.89||||2.89|0.86|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.89||||2.89|1.27|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.89||||2.89|0.86|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.89||||2.89|0.86|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.89||||2.89|1.99|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.89||||2.89|0.86|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.89||||2.89|1.01|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.89||||2.89|0.86|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.89||||2.89|0.86|1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.89||||2.89||1.99|0.86
4064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.89||||2.89||1.99|0.86
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.14||||3.14|1.38|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.14||||3.14|0.93|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.14||||3.14|1.48|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.14||||3.14|1.57|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.14||||3.14|1.57|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.14||||3.14|1.98|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.14||||3.14|0.93|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.14||||3.14|1.73|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.14||||3.14|2.17|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.14||||3.14|1.57|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.14||||3.14|1.38|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.14||||3.14|0.93|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.14||||3.14|1.38|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.14||||3.14|0.93|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.14||||3.14|0.93|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.14||||3.14|2.17|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.14||||3.14|0.93|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|Self-pay|Self-pay|3.14||||3.14|1.1|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.14||||3.14|0.93|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.14||||3.14|0.93|2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.14||||3.14||2.17|0.93
4065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.14||||3.14||2.17|0.93
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|AARP [1000]|AARP [100000]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|AETNA [1015]|AETNA [101529]|4.89||||4.89|2.16|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.89||||4.89|1.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.89||||4.89|2.3|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.89||||4.89|2.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.89||||4.89|2.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.89||||4.89|3.08|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.89||||4.89|1.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.89||||4.89|2.69|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.89||||4.89|3.37|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.89||||4.89|2.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.89||||4.89|2.16|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.89||||4.89|1.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.89||||4.89|2.16|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.89||||4.89|1.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.89||||4.89|1.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.89||||4.89|3.37|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.89||||4.89|1.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|Self-pay|Self-pay|4.89||||4.89|1.71|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.89||||4.89|1.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.89||||4.89|1.45|3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.89||||4.89||3.37|1.45
4068|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ISOSORBIDE DINITRATE 5 MG TABLET|2 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.89||||4.89||3.37|1.45
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|AARP [1000]|AARP [100000]|8401.41||||8401.41|4200.71|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8401.41||||8401.41|842.89|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|AETNA [1015]|AETNA [101529]|8401.41||||8401.41|2964.82|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8401.41||||8401.41|2491.02|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8401.41||||8401.41|834.54|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8401.41||||8401.41|834.54|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|BCBS [1155]|BCBS UTHCT [115568]|8401.41||||8401.41|3948.66|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8401.41||||8401.41|0|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8401.41||||8401.41|4200.71|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8401.41||||8401.41|5292.89|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8401.41||||8401.41|2491.02|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8401.41||||8401.41|834.54|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|CIGNA [1260]|CIGNA GWH [126023]|8401.41||||8401.41|4200.71|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|8401.41||||8401.41|5796.97|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8401.41||||8401.41|286.16|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8401.41||||8401.41|834.54|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8401.41||||8401.41|2964.82|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8401.41||||8401.41|2491.02|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8401.41||||8401.41|834.54|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8401.41||||8401.41|2964.82|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8401.41||||8401.41|2491.02|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|8401.41||||8401.41|2491.02|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|8401.41||||8401.41|5796.97|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8401.41||||8401.41|2491.02|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|Self-pay|Self-pay|8401.41||||8401.41|2940.49|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8401.41||||8401.41|2491.02|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8401.41||||8401.41|2491.02|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8401.41||||8401.41|4200.71|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8401.41||||8401.41|834.54|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8401.41||||8401.41|834.54|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8401.41||||8401.41|4200.71|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8401.41||||8401.41|834.54|5796.97|286.16
40801|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUPROLIDE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE|45 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8401.41||||8401.41|1669.08|5796.97|286.16
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|AARP [1000]|AARP [100000]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|AETNA [1015]|AETNA [101529]|12.4||||12.4|8.42|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.4||||12.4|3.68|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|12.4||||12.4|5.83|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.4||||12.4|0|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.4||||12.4|6.2|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.4||||12.4|7.81|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.4||||12.4|3.68|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|12.4||||12.4|6.82|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.4||||12.4|8.56|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.4||||12.4|4.91|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.4||||12.4|8.42|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.4||||12.4|3.68|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.4||||12.4|8.42|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.4||||12.4|3.68|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.4||||12.4|3.68|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.4||||12.4|8.56|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.4||||12.4|3.68|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|Self-pay|Self-pay|12.4||||12.4|4.34|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.4||||12.4|3.68|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.4||||12.4|3.68|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.4||||12.4||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|AARP [1000]|AARP [100000]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|AETNA [1015]|AETNA [101529]|3.1||||3.1|3.1|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.1||||3.1|0.92|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|BCBS [1155]|BCBS UTHCT [115568]|3.1||||3.1|1.46|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.1||||3.1|0|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.1||||3.1|1.55|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.1||||3.1|1.95|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.1||||3.1|0.92|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|CIGNA [1260]|CIGNA GWH [126023]|3.1||||3.1|1.71|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.1||||3.1|2.14|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.1||||3.1|4.91|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.1||||3.1|3.1|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.1||||3.1|0.92|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.1||||3.1|3.1|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.1||||3.1|0.92|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.1||||3.1|0.92|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.1||||3.1|2.14|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.1||||3.1|0.92|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|Self-pay|Self-pay|3.1||||3.1|1.08|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.1||||3.1|0.92|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.1||||3.1|0.92|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.1||||3.1||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|AARP [1000]|AARP [100000]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|AETNA [1015]|AETNA [101529]|6.2||||6.2|6.2|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.2||||6.2|1.84|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|BCBS [1155]|BCBS UTHCT [115568]|6.2||||6.2|2.91|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.2||||6.2|0|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.2||||6.2|3.1|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.2||||6.2|3.91|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.2||||6.2|1.84|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|CIGNA [1260]|CIGNA GWH [126023]|6.2||||6.2|3.41|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.2||||6.2|4.28|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.2||||6.2|4.91|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.2||||6.2|6.2|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.2||||6.2|1.84|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.2||||6.2|6.2|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.2||||6.2|1.84|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.2||||6.2|1.84|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.2||||6.2|4.28|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.2||||6.2|1.84|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|Self-pay|Self-pay|6.2||||6.2|2.17|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.2||||6.2|1.84|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.2||||6.2|1.84|8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.2||||6.2||8.56|0.92
40802364|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % IN WATER (D5W) INTRAVENOUS SOLUTION *BAG NON-PVC/NON-DEHP*|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.2||||6.2||8.56|0.92
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AARP [1000]|AARP [100000]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.13||||0.13|0.06|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.13||||0.13|0.04|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.13||||0.13|0.06|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.13||||0.13|0.07|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.13||||0.13|0.07|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.13||||0.13|0.08|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.13||||0.13|0.04|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.13||||0.13|0.07|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.13||||0.13|0.09|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.13||||0.13|0.07|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.13||||0.13|0.06|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.13||||0.13|0.04|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.13||||0.13|0.06|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.13||||0.13|0.04|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.13||||0.13|0.04|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.13||||0.13|0.09|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.13||||0.13|0.04|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|Self-pay|Self-pay|0.13||||0.13|0.05|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.13||||0.13|0.04|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.13||||0.13|0.04|0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.13||||0.13||0.09|0.04
40807877|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIAMINE (VITAMIN B1) 100 MG TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.13||||0.13||0.09|0.04
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|AARP [1000]|AARP [100000]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|AETNA [1015]|AETNA [101529]|10.36||||10.36|6|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.36||||10.36|3.07|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|BCBS [1155]|BCBS UTHCT [115568]|10.36||||10.36|4.87|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.36||||10.36|0|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.36||||10.36|5.18|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.36||||10.36|6.53|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.36||||10.36|3.07|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|CIGNA [1260]|CIGNA GWH [126023]|10.36||||10.36|5.7|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.36||||10.36|7.15|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.36||||10.36|0.4|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.36||||10.36|6|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.36||||10.36|3.07|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.36||||10.36|6|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.36||||10.36|3.07|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.36||||10.36|3.07|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.36||||10.36|7.15|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.36||||10.36|3.07|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|Self-pay|Self-pay|10.36||||10.36|3.63|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.36||||10.36|3.07|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.36||||10.36|3.07|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.36||||10.36||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|AARP [1000]|AARP [100000]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|AETNA [1015]|AETNA [101529]|21.12||||21.12|18|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.12||||21.12|6.26|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|BCBS [1155]|BCBS UTHCT [115568]|21.12||||21.12|9.93|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.12||||21.12|0|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.12||||21.12|10.56|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.12||||21.12|13.31|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.12||||21.12|6.26|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|CIGNA [1260]|CIGNA GWH [126023]|21.12||||21.12|11.62|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.12||||21.12|14.57|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.12||||21.12|0.4|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.12||||21.12|18|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.12||||21.12|6.26|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.12||||21.12|18|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.12||||21.12|6.26|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.12||||21.12|6.26|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.12||||21.12|14.57|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.12||||21.12|6.26|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|Self-pay|Self-pay|21.12||||21.12|7.39|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.12||||21.12|6.26|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.12||||21.12|6.26|18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.12||||21.12||18|0.4
4081017602|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - HIGH PTT CALCULATOR|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|AARP [1000]|AARP [100000]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|AETNA [1015]|AETNA [101529]|10.36||||10.36|6|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.36||||10.36|3.07|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|BCBS [1155]|BCBS UTHCT [115568]|10.36||||10.36|4.87|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.36||||10.36|0|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.36||||10.36|5.18|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.36||||10.36|6.53|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.36||||10.36|3.07|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|CIGNA [1260]|CIGNA GWH [126023]|10.36||||10.36|5.7|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.36||||10.36|7.15|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.36||||10.36|0.4|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.36||||10.36|6|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.36||||10.36|3.07|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.36||||10.36|6|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.36||||10.36|3.07|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.36||||10.36|3.07|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.36||||10.36|7.15|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.36||||10.36|3.07|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|Self-pay|Self-pay|10.36||||10.36|3.63|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.36||||10.36|3.07|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.36||||10.36|3.07|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.36||||10.36||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|AARP [1000]|AARP [100000]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|AETNA [1015]|AETNA [101529]|21.12||||21.12|18|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.12||||21.12|6.26|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|BCBS [1155]|BCBS UTHCT [115568]|21.12||||21.12|9.93|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.12||||21.12|0|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.12||||21.12|10.56|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.12||||21.12|13.31|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.12||||21.12|6.26|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|CIGNA [1260]|CIGNA GWH [126023]|21.12||||21.12|11.62|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.12||||21.12|14.57|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.12||||21.12|0.4|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.12||||21.12|18|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.12||||21.12|6.26|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.12||||21.12|18|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.12||||21.12|6.26|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.12||||21.12|6.26|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.12||||21.12|14.57|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.12||||21.12|6.26|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|Self-pay|Self-pay|21.12||||21.12|7.39|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.12||||21.12|6.26|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.12||||21.12|6.26|18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.12||||21.12||18|0.4
4081017604|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN (PORCINE) 1,000 UNIT/ML INJECTION SOLUTION - LOW PTT CALCULATOR|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.12||||21.12||18|0.4
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|AARP [1000]|AARP [100000]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|AETNA [1015]|AETNA [101529]|138.3||||138.3|119.52|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138.3||||138.3|41.01|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|BCBS [1155]|BCBS UTHCT [115568]|138.3||||138.3|65|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138.3||||138.3|0|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138.3||||138.3|69.15|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138.3||||138.3|87.13|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138.3||||138.3|41.01|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|CIGNA [1260]|CIGNA GWH [126023]|138.3||||138.3|76.07|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|138.3||||138.3|95.43|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138.3||||138.3|69.15|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138.3||||138.3|119.52|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138.3||||138.3|41.01|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138.3||||138.3|119.52|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138.3||||138.3|41.01|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|138.3||||138.3|41.01|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|138.3||||138.3|95.43|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138.3||||138.3|41.01|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|Self-pay|Self-pay|138.3||||138.3|48.4|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138.3||||138.3|41.01|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138.3||||138.3|41.01|119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138.3||||138.3||119.52|41.01
40810289|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN REGULAR NON-DKA CALCULATOR BOLUS DOSE|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138.3||||138.3||119.52|41.01
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|AARP [1000]|AARP [100000]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|6.33||||6.33|2.79|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.33||||6.33|1.88|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|BCBS [1155]|BCBS UTHCT [115568]|6.33||||6.33|2.98|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.33||||6.33|3.17|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.33||||6.33|3.17|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.33||||6.33|3.99|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.33||||6.33|1.88|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|CIGNA [1260]|CIGNA GWH [126023]|6.33||||6.33|3.48|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.33||||6.33|4.37|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.33||||6.33|3.17|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.33||||6.33|2.79|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.33||||6.33|1.88|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.33||||6.33|2.79|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.33||||6.33|1.88|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.33||||6.33|1.88|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.33||||6.33|4.37|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.33||||6.33|1.88|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|Self-pay|Self-pay|6.33||||6.33|2.22|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.33||||6.33|1.88|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.33||||6.33|1.88|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.33||||6.33||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|AARP [1000]|AARP [100000]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|AETNA [1015]|AETNA [101529]|31.81||||31.81|14.03|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31.81||||31.81|9.43|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|BCBS [1155]|BCBS UTHCT [115568]|31.81||||31.81|14.95|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31.81||||31.81|15.91|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31.81||||31.81|15.91|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31.81||||31.81|20.04|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31.81||||31.81|9.43|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|CIGNA [1260]|CIGNA GWH [126023]|31.81||||31.81|17.5|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|31.81||||31.81|21.95|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31.81||||31.81|15.91|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31.81||||31.81|14.03|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31.81||||31.81|9.43|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31.81||||31.81|14.03|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31.81||||31.81|9.43|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|31.81||||31.81|9.43|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|31.81||||31.81|21.95|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31.81||||31.81|9.43|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|Self-pay|Self-pay|31.81||||31.81|11.13|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31.81||||31.81|9.43|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31.81||||31.81|9.43|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31.81||||31.81||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AARP [1000]|AARP [100000]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AETNA [1015]|AETNA [101529]|10.51||||10.51|4.63|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.51||||10.51|3.12|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|10.51||||10.51|4.94|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.51||||10.51|5.26|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.51||||10.51|5.26|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.51||||10.51|6.62|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.51||||10.51|3.12|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|10.51||||10.51|5.78|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.51||||10.51|7.25|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.51||||10.51|5.26|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.51||||10.51|4.63|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.51||||10.51|3.12|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.51||||10.51|4.63|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.51||||10.51|3.12|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.51||||10.51|3.12|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.51||||10.51|7.25|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.51||||10.51|3.12|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|Self-pay|Self-pay|10.51||||10.51|3.68|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.51||||10.51|3.12|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.51||||10.51|3.12|21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.51||||10.51||21.95|1.88
408104207|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 10 MG/ML (1%) INJECTION SOLUTION WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.51||||10.51||21.95|1.88
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|AARP [1000]|AARP [100000]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|AETNA [1015]|AETNA [101529]|15.26||||15.26|6.73|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.26||||15.26|4.52|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|BCBS [1155]|BCBS UTHCT [115568]|15.26||||15.26|7.17|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.26||||15.26|7.63|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.26||||15.26|7.63|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.26||||15.26|9.61|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.26||||15.26|4.52|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|CIGNA [1260]|CIGNA GWH [126023]|15.26||||15.26|8.39|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.26||||15.26|10.53|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.26||||15.26|7.63|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.26||||15.26|6.73|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.26||||15.26|4.52|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.26||||15.26|6.73|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.26||||15.26|4.52|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.26||||15.26|4.52|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.26||||15.26|10.53|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.26||||15.26|4.52|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|Self-pay|Self-pay|15.26||||15.26|5.34|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.26||||15.26|4.52|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.26||||15.26|4.52|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.26||||15.26||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|10.34||||10.34|4.56|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.34||||10.34|3.07|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|BCBS [1155]|BCBS UTHCT [115568]|10.34||||10.34|4.86|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.34||||10.34|5.17|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.34||||10.34|5.17|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.34||||10.34|6.51|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.34||||10.34|3.07|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA GWH [126023]|10.34||||10.34|5.69|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.34||||10.34|7.13|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.34||||10.34|5.17|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.34||||10.34|4.56|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.34||||10.34|3.07|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.34||||10.34|4.56|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.34||||10.34|3.07|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.34||||10.34|3.07|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.34||||10.34|7.13|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.34||||10.34|3.07|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|Self-pay|Self-pay|10.34||||10.34|3.62|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.34||||10.34|3.07|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.34||||10.34|3.07|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.34||||10.34||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AARP [1000]|AARP [100000]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AETNA [1015]|AETNA [101529]|7.63||||7.63|3.36|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.63||||7.63|2.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|7.63||||7.63|3.59|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.63||||7.63|3.82|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.63||||7.63|3.82|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.63||||7.63|4.81|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.63||||7.63|2.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|7.63||||7.63|4.2|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.63||||7.63|5.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.63||||7.63|3.82|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.63||||7.63|3.36|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.63||||7.63|2.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.63||||7.63|3.36|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.63||||7.63|2.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.63||||7.63|2.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.63||||7.63|5.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.63||||7.63|2.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|Self-pay|Self-pay|7.63||||7.63|2.67|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.63||||7.63|2.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.63||||7.63|2.26|10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.63||||7.63||10.53|2.26
408104208|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 20 MG/ML (2%) INJECTION WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.63||||7.63||10.53|2.26
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AARP [1000]|AARP [100000]|316.55||||316.55||218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|316.55||||316.55|82.3|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AETNA [1015]|AETNA [101529]|316.55||||316.55|139.6|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|316.55||||316.55|93.86|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|316.55||||316.55|82.3|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|316.55||||316.55|82.3|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|316.55||||316.55|148.78|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|316.55||||316.55|0|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|316.55||||316.55|158.28|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|316.55||||316.55|199.43|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|316.55||||316.55|93.86|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|316.55||||316.55|82.3|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|316.55||||316.55|174.1|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|316.55||||316.55|218.42|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|316.55||||316.55|149.9|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|316.55||||316.55|82.3|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|316.55||||316.55|139.6|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|316.55||||316.55|93.86|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|316.55||||316.55|82.3|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|316.55||||316.55|139.6|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|316.55||||316.55|93.86|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|316.55||||316.55|93.86|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|316.55||||316.55|218.42|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|316.55||||316.55|93.86|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|Self-pay|Self-pay|316.55||||316.55|110.79|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|316.55||||316.55|93.86|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|316.55||||316.55|93.86|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|316.55||||316.55||218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|316.55||||316.55|82.3|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|316.55||||316.55|82.3|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|316.55||||316.55||218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|316.55||||316.55|82.3|218.42|82.3
40811037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PNEUMOCOCCAL 23 POLYVALENT VACCINE 25 MCG/0.5 ML INJECTION WRAP|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|316.55||||316.55|164.61|218.42|82.3
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|AARP [1000]|AARP [100000]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|AETNA [1015]|AETNA [101529]|12.16||||12.16|5.11|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.16||||12.16|3.61|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|BCBS [1155]|BCBS UTHCT [115568]|12.16||||12.16|5.72|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.16||||12.16|0|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.16||||12.16|6.08|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.16||||12.16|7.66|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.16||||12.16|3.61|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|CIGNA [1260]|CIGNA GWH [126023]|12.16||||12.16|6.69|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.16||||12.16|8.39|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.16||||12.16|2.63|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.16||||12.16|5.11|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.16||||12.16|3.61|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.16||||12.16|5.11|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.16||||12.16|3.61|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.16||||12.16|3.61|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.16||||12.16|8.39|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.16||||12.16|3.61|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|Self-pay|Self-pay|12.16||||12.16|4.26|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.16||||12.16|3.61|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.16||||12.16|3.61|8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.16||||12.16||8.39|2.63
408117032|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM (PF) 25 MG/ML IM USE FOR ECTOPIC PG|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.16||||12.16||8.39|2.63
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AARP [1000]|AARP [100000]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AETNA [1015]|AETNA [101529]|27.13||||27.13|11.96|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.13||||27.13|8.04|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BCBS UTHCT [115568]|27.13||||27.13|12.75|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.13||||27.13|13.57|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.13||||27.13|13.57|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.13||||27.13|17.09|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.13||||27.13|8.04|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|CIGNA [1260]|CIGNA GWH [126023]|27.13||||27.13|14.92|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.13||||27.13|18.72|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.13||||27.13|13.57|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.13||||27.13|11.96|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.13||||27.13|8.04|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.13||||27.13|11.96|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.13||||27.13|8.04|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.13||||27.13|8.04|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.13||||27.13|18.72|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.13||||27.13|8.04|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|Self-pay|Self-pay|27.13||||27.13|9.5|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.13||||27.13|8.04|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.13||||27.13|8.04|18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.13||||27.13||18.72|8.04
408121844|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 1 MEQ/ML (8.4%) IV WRAP|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.13||||27.13||18.72|8.04
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AARP [1000]|AARP [100000]|0.72||||0.72|0.72|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.72||||0.72||3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AETNA [1015]|AETNA [101529]|0.72||||0.72|0.72|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.72||||0.72|0.21|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.72||||0.72||3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.72||||0.72||3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS [1155]|BCBS UTHCT [115568]|0.72||||0.72|0.34|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.72||||0.72|0|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.72||||0.72|0.36|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.72||||0.72|0.45|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.72||||0.72|0.21|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.72||||0.72||3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|CIGNA [1260]|CIGNA GWH [126023]|0.72||||0.72|0.4|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.72||||0.72|0.5|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.72||||0.72|3.94|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.72||||0.72||3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.72||||0.72|0.72|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.72||||0.72|0.21|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.72||||0.72||3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.72||||0.72|0.72|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.72||||0.72|0.21|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.72||||0.72|0.21|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.72||||0.72|0.5|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.72||||0.72|0.21|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|Self-pay|Self-pay|0.72||||0.72|0.25|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.72||||0.72|0.21|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.72||||0.72|0.21|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.72||||0.72|0.72|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.72||||0.72||3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.72||||0.72||3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.72||||0.72|0.72|3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.72||||0.72||3.94|0.21
408123415|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 10 MG/ML INJECTION WRAP|0.1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.72||||0.72||3.94|0.21
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|7.87||||7.87|7.7|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.87||||7.87||7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|7.87||||7.87|7.87|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.87||||7.87|2.33|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.87||||7.87||7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.87||||7.87||7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|7.87||||7.87|3.7|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.87||||7.87|0|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.87||||7.87|3.94|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.87||||7.87|4.96|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.87||||7.87|2.33|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.87||||7.87||7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|7.87||||7.87|4.33|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.87||||7.87|5.43|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.87||||7.87|6.68|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.87||||7.87||7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.87||||7.87|7.87|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.87||||7.87|2.33|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.87||||7.87||7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.87||||7.87|7.87|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.87||||7.87|2.33|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.87||||7.87|2.33|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.87||||7.87|5.43|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.87||||7.87|2.33|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|7.87||||7.87|2.75|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.87||||7.87|2.33|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.87||||7.87|2.33|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.87||||7.87|7.7|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.87||||7.87||7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.87||||7.87||7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.87||||7.87|7.7|7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.87||||7.87||7.87|2.33
408125728|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 25 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.87||||7.87||7.87|2.33
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AARP [1000]|AARP [100000]|0.62||||0.62|0.62|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.62||||0.62||0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AETNA [1015]|AETNA [101529]|0.62||||0.62|0.24|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.62||||0.62|0.18|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.62||||0.62||0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.62||||0.62||0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|0.62||||0.62|0.29|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.62||||0.62|0|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.62||||0.62|0.31|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.62||||0.62|0.39|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.62||||0.62|0.18|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.62||||0.62||0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|0.62||||0.62|0.34|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.62||||0.62|0.43|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.62||||0.62|0.03|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.62||||0.62||0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.62||||0.62|0.24|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.62||||0.62|0.18|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.62||||0.62||0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.62||||0.62|0.24|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.62||||0.62|0.18|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.62||||0.62|0.18|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.62||||0.62|0.43|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.62||||0.62|0.18|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|Self-pay|Self-pay|0.62||||0.62|0.22|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.62||||0.62|0.18|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.62||||0.62|0.18|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.62||||0.62|0.62|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.62||||0.62||0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.62||||0.62||0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.62||||0.62|0.62|0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.62||||0.62||0.62|0.03
408125938|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPARIN, PORCINE (PF) 100 UNIT/ML IV WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.62||||0.62||0.62|0.03
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|246.42||||246.42|203.76|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|246.42||||246.42|73.06|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|BCBS [1155]|BCBS UTHCT [115568]|246.42||||246.42|115.82|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|246.42||||246.42|0|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|246.42||||246.42|123.21|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|246.42||||246.42|155.24|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|246.42||||246.42|73.06|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA GWH [126023]|246.42||||246.42|135.53|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|246.42||||246.42|170.03|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|246.42||||246.42|100.45|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|246.42||||246.42|203.76|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|246.42||||246.42|73.06|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|246.42||||246.42|203.76|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|246.42||||246.42|73.06|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|246.42||||246.42|73.06|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|246.42||||246.42|170.03|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|246.42||||246.42|73.06|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|Self-pay|Self-pay|246.42||||246.42|86.25|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|246.42||||246.42|73.06|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|246.42||||246.42|73.06|203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|246.42||||246.42||203.76|73.06
40812772|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|RHO(D) IMMUNE GLOBULIN 1,500 UNIT (300 MCG) INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|246.42||||246.42||203.76|73.06
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AARP [1000]|AARP [100000]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AETNA [1015]|AETNA [101529]|25.61||||25.61|11.29|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.61||||25.61|7.59|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS [1155]|BCBS UTHCT [115568]|25.61||||25.61|12.04|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.61||||25.61|12.81|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.61||||25.61|12.81|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.61||||25.61|16.13|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.61||||25.61|7.59|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|CIGNA [1260]|CIGNA GWH [126023]|25.61||||25.61|14.09|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|GROUP PENSION ADMIN [1450]|GPA [145000]|25.61||||25.61|17.67|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25.61||||25.61|12.81|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.61||||25.61|11.29|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.61||||25.61|7.59|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.61||||25.61|11.29|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.61||||25.61|7.59|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|25.61||||25.61|7.59|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|PHCS [1780]|PHCS MULTIPLAN [178000]|25.61||||25.61|17.67|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.61||||25.61|7.59|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|Self-pay|Self-pay|25.61||||25.61|8.96|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25.61||||25.61|7.59|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.61||||25.61|7.59|17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.61||||25.61||17.67|7.59
408128130|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM-MINERAL OIL EYE OINTMENT WRAP|4 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.61||||25.61||17.67|7.59
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AARP [1000]|AARP [100000]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AARP [1000]|AARP [100000]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AETNA [1015]|AETNA [101529]|1.91||||1.91|0.84|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AETNA [1015]|AETNA [101529]|1.91||||1.91|0.84|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BCBS UTHCT [115568]|1.91||||1.91|0.9|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BCBS UTHCT [115568]|1.91||||1.91|0.9|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.91||||1.91|0.96|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.91||||1.91|0.96|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.91||||1.91|0.96|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.91||||1.91|0.96|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.91||||1.91|1.2|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.91||||1.91|1.2|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA [1260]|CIGNA GWH [126023]|1.91||||1.91|1.05|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|CIGNA [1260]|CIGNA GWH [126023]|1.91||||1.91|1.05|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.91||||1.91|1.32|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.91||||1.91|1.32|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.91||||1.91|0.96|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.91||||1.91|0.96|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.91||||1.91|0.84|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.91||||1.91|0.84|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.91||||1.91|0.84|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.91||||1.91|0.84|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.91||||1.91|1.32|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.91||||1.91|1.32|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|Self-pay|Self-pay|1.91||||1.91|0.67|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|Self-pay|Self-pay|1.91||||1.91|0.67|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.91||||1.91|0.57|1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.91||||1.91||1.32|0.57
408131110|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACTULOSE 10 GRAM/15 ML ORAL SOLUTION WRAP|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.91||||1.91||1.32|0.57
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|112.22||||112.22|49.49|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|112.22||||112.22|33.27|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|112.22||||112.22|52.74|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|112.22||||112.22|56.11|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|112.22||||112.22|56.11|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|112.22||||112.22|70.7|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|112.22||||112.22|33.27|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|112.22||||112.22|61.72|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|112.22||||112.22|77.43|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|112.22||||112.22|56.11|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|112.22||||112.22|49.49|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|112.22||||112.22|33.27|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|112.22||||112.22|49.49|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|112.22||||112.22|33.27|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|112.22||||112.22|33.27|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|112.22||||112.22|77.43|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|112.22||||112.22|33.27|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|112.22||||112.22|39.28|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|112.22||||112.22|33.27|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|112.22||||112.22|33.27|77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|112.22||||112.22||77.43|33.27
408165088|ERX|0250 - PHARMACY-GENERAL|EPHEDRINE SULFATE 50 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|112.22||||112.22||77.43|33.27
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AARP [1000]|AARP [100000]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AETNA [1015]|AETNA [101529]|59.34||||59.34|26.17|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.34||||59.34|17.59|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS [1155]|BCBS UTHCT [115568]|59.34||||59.34|27.89|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.34||||59.34|29.67|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.34||||59.34|29.67|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.34||||59.34|37.38|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.34||||59.34|17.59|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|CIGNA [1260]|CIGNA GWH [126023]|59.34||||59.34|32.64|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.34||||59.34|40.94|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|59.34||||59.34|29.67|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.34||||59.34|26.17|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.34||||59.34|17.59|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.34||||59.34|26.17|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.34||||59.34|17.59|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|59.34||||59.34|17.59|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.34||||59.34|40.94|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.34||||59.34|17.59|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|Self-pay|Self-pay|59.34||||59.34|20.77|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|59.34||||59.34|17.59|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.34||||59.34|17.59|40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.34||||59.34||40.94|17.59
408165389|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM POLYSTYRENE SULFONATE 15 GRAM/60 ML ORAL SUSPENSION WRAP REPACK|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.34||||59.34||40.94|17.59
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AARP [1000]|AARP [100000]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AETNA [1015]|AETNA [101529]|41.08||||41.08|18.12|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.08||||41.08|12.18|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BCBS UTHCT [115568]|41.08||||41.08|19.31|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.08||||41.08|20.54|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.08||||41.08|20.54|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.08||||41.08|25.88|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.08||||41.08|12.18|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|CIGNA [1260]|CIGNA GWH [126023]|41.08||||41.08|22.59|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|41.08||||41.08|28.35|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.08||||41.08|20.54|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.08||||41.08|18.12|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.08||||41.08|12.18|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.08||||41.08|18.12|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.08||||41.08|12.18|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.08||||41.08|12.18|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|41.08||||41.08|28.35|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.08||||41.08|12.18|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|Self-pay|Self-pay|41.08||||41.08|14.38|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.08||||41.08|12.18|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.08||||41.08|12.18|28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.08||||41.08||28.35|12.18
4082365|ERX|0250 - PHARMACY-GENERAL|DEXTROSE 50 % IN WATER (D50W) INTRAVENOUS WRAP|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.08||||41.08||28.35|12.18
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|AARP [1000]|AARP [100000]|15750||||15750|7875|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15750||||15750||10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|AETNA [1015]|AETNA [101529]|15750||||15750|6945.75|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15750||||15750|4669.88|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15750||||15750||10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15750||||15750||10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|BCBS [1155]|BCBS UTHCT [115568]|15750||||15750|7402.5|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15750||||15750|0|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15750||||15750|7875|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15750||||15750|9922.5|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15750||||15750|4669.88|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15750||||15750||10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|CIGNA [1260]|CIGNA GWH [126023]|15750||||15750|8662.5|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|15750||||15750|10867.5|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15750||||15750|7875|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15750||||15750||10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15750||||15750|6945.75|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15750||||15750|4669.88|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15750||||15750||10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15750||||15750|6945.75|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15750||||15750|4669.88|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|15750||||15750|4669.88|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|15750||||15750|10867.5|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15750||||15750|4669.88|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|Self-pay|Self-pay|15750||||15750|5512.5|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15750||||15750|4669.88|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15750||||15750|4669.88|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15750||||15750|7875|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15750||||15750||10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15750||||15750||10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15750||||15750|7875|10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15750||||15750||10867.5|4669.88
408240060|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO GA68 GALLIUM DOTATATE PER 0.1 MCI|1 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15750||||15750||10867.5|4669.88
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|AARP [1000]|AARP [100000]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|AETNA [1015]|AETNA [101529]|879.04||||879.04|398.4|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|879.04||||879.04|260.64|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|BCBS [1155]|BCBS UTHCT [115568]|879.04||||879.04|413.15|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|879.04||||879.04|0|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|879.04||||879.04|439.52|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|879.04||||879.04|553.8|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|879.04||||879.04|260.64|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|CIGNA [1260]|CIGNA GWH [126023]|879.04||||879.04|439.52|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|879.04||||879.04|606.54|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|879.04||||879.04|439.52|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|879.04||||879.04|398.4|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|879.04||||879.04|260.64|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|879.04||||879.04|398.4|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|879.04||||879.04|260.64|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|879.04||||879.04|260.64|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|879.04||||879.04|606.54|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|879.04||||879.04|260.64|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|Self-pay|Self-pay|879.04||||879.04|307.66|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|879.04||||879.04|260.64|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|879.04||||879.04|260.64|606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|879.04||||879.04||606.54|260.64
4082828201|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN GLARGINE 100 UNIT/ML SUBCUTANEOUS SOLUTION NON-BULK|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|879.04||||879.04||606.54|260.64
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AARP [1000]|AARP [100000]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AETNA [1015]|AETNA [101529]|1.03||||1.03|0.45|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.03||||1.03|0.31|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.03||||1.03|0.48|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.03||||1.03|0.52|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.03||||1.03|0.52|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.03||||1.03|0.65|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.03||||1.03|0.31|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.03||||1.03|0.57|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.03||||1.03|0.71|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.03||||1.03|0.52|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.03||||1.03|0.45|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.03||||1.03|0.31|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.03||||1.03|0.45|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.03||||1.03|0.31|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.03||||1.03|0.31|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.03||||1.03|0.71|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.03||||1.03|0.31|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|Self-pay|Self-pay|1.03||||1.03|0.36|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.03||||1.03|0.31|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.03||||1.03|0.31|0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.03||||1.03||0.71|0.31
40829270|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 120 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.03||||1.03||0.71|0.31
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AARP [1000]|AARP [100000]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AETNA [1015]|AETNA [101529]|1.21||||1.21|0.53|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.21||||1.21|0.36|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.21||||1.21|0.57|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.21||||1.21|0.61|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.21||||1.21|0.61|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.21||||1.21|0.76|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.21||||1.21|0.36|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.21||||1.21|0.67|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.21||||1.21|0.83|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.21||||1.21|0.61|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.21||||1.21|0.53|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.21||||1.21|0.36|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.21||||1.21|0.53|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.21||||1.21|0.36|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.21||||1.21|0.36|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.21||||1.21|0.83|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.21||||1.21|0.36|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|Self-pay|Self-pay|1.21||||1.21|0.42|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.21||||1.21|0.36|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.21||||1.21|0.36|0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.21||||1.21||0.83|0.36
40829272|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DILTIAZEM 180 MG CAPSULE,EXTENDED RELEASE 24 HR WRAP|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.21||||1.21||0.83|0.36
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|AARP [1000]|AARP [100000]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|AETNA [1015]|AETNA [101529]|123.43||||123.43|41.18|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|123.43||||123.43|36.6|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|BCBS [1155]|BCBS UTHCT [115568]|123.43||||123.43|58.01|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|123.43||||123.43|0|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|123.43||||123.43|61.72|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|123.43||||123.43|77.76|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|123.43||||123.43|36.6|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|CIGNA [1260]|CIGNA GWH [126023]|123.43||||123.43|67.89|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|123.43||||123.43|85.17|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|123.43||||123.43|0.16|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|123.43||||123.43|41.18|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|123.43||||123.43|36.6|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|123.43||||123.43|41.18|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|123.43||||123.43|36.6|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|123.43||||123.43|36.6|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|123.43||||123.43|85.17|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|123.43||||123.43|36.6|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|Self-pay|Self-pay|123.43||||123.43|43.2|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|123.43||||123.43|36.6|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|123.43||||123.43|36.6|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|237 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|123.43||||123.43||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|AARP [1000]|AARP [100000]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|AETNA [1015]|AETNA [101529]|2.61||||2.61|0.86|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.61||||2.61|0.77|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|2.61||||2.61|1.23|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.61||||2.61|0|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.61||||2.61|1.31|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.61||||2.61|1.64|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.61||||2.61|0.77|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|2.61||||2.61|1.44|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.61||||2.61|1.8|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.61||||2.61|0.16|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.61||||2.61|0.86|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.61||||2.61|0.77|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.61||||2.61|0.86|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.61||||2.61|0.77|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.61||||2.61|0.77|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.61||||2.61|1.8|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.61||||2.61|0.77|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|Self-pay|Self-pay|2.61||||2.61|0.91|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.61||||2.61|0.77|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.61||||2.61|0.77|85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.61||||2.61||85.17|0.16
40829302|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISOLONE SODIUM PHOSPHATE 3 MG/ML ORAL SOLUTION WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.61||||2.61||85.17|0.16
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AARP [1000]|AARP [100000]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AETNA [1015]|AETNA [101529]|1.86||||1.86|0.82|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.86||||1.86|0.55|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.86||||1.86|0.87|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.86||||1.86|0.93|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.86||||1.86|0.93|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.86||||1.86|1.17|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.86||||1.86|0.55|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.86||||1.86|1.02|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.86||||1.86|1.28|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.86||||1.86|0.93|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.86||||1.86|0.82|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.86||||1.86|0.55|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.86||||1.86|0.82|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.86||||1.86|0.55|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.86||||1.86|0.55|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.86||||1.86|1.28|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.86||||1.86|0.55|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|Self-pay|Self-pay|1.86||||1.86|0.65|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.86||||1.86|0.55|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.86||||1.86|0.55|1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.86||||1.86||1.28|0.55
40835942|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE ER 10 MEQ TABLET,EXTENDED RELEASE WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.86||||1.86||1.28|0.55
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AARP [1000]|AARP [100000]|12.87||||12.87|6.67|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.87||||12.87||8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AETNA [1015]|AETNA [101529]|12.87||||12.87|7.46|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.87||||12.87|3.82|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.87||||12.87||8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.87||||12.87||8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|12.87||||12.87|6.05|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.87||||12.87|0|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.87||||12.87|6.44|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.87||||12.87|8.11|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.87||||12.87|3.82|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.87||||12.87||8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|12.87||||12.87|7.08|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.87||||12.87|8.88|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.87||||12.87|3.43|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.87||||12.87||8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.87||||12.87|7.46|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.87||||12.87|3.82|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.87||||12.87||8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.87||||12.87|7.46|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.87||||12.87|3.82|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.87||||12.87|3.82|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.87||||12.87|8.88|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.87||||12.87|3.82|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|Self-pay|Self-pay|12.87||||12.87|4.5|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.87||||12.87|3.82|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.87||||12.87|3.82|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.87||||12.87|6.67|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.87||||12.87||8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.87||||12.87||8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.87||||12.87|6.67|8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.87||||12.87||8.88|3.43
4083757|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 1 MG/ML INJECTION  WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.87||||12.87||8.88|3.43
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AARP [1000]|AARP [100000]|93||||93|27|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|93||||93||64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AETNA [1015]|AETNA [101529]|93||||93|26.4|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|93||||93|27.57|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|93||||93||64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|93||||93||64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|BCBS [1155]|BCBS UTHCT [115568]|93||||93|43.71|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|93||||93|0|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|93||||93|46.5|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|93||||93|58.59|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|93||||93|27.57|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|93||||93||64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|CIGNA [1260]|CIGNA GWH [126023]|93||||93|51.15|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|93||||93|64.17|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|93||||93|0.15|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|93||||93||64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|93||||93|26.4|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|93||||93|27.57|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|93||||93||64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|93||||93|26.4|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|93||||93|27.57|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|93||||93|27.57|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|93||||93|64.17|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|93||||93|27.57|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|Self-pay|Self-pay|93||||93|32.55|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|93||||93|27.57|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|93||||93|27.57|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|93||||93|27|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|93||||93||64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|93||||93||64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|93||||93|27|64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|93||||93||64.17|0.15
40840026|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROPOFOL INFUSION 10 MG/ML|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|93||||93||64.17|0.15
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|AARP [1000]|AARP [100000]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|AETNA [1015]|AETNA [101529]|630||||630|0|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|630||||630|186.8|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BCBS UTHCT [115568]|630||||630|296.1|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|630||||630|0|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|630||||630|315|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|630||||630|396.9|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|630||||630|186.8|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|CIGNA [1260]|CIGNA GWH [126023]|630||||630|346.5|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|630||||630|434.7|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|630||||630|315|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|630||||630|0|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|630||||630|186.8|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|630||||630|0|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|630||||630|186.8|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|630||||630|186.8|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|630||||630|434.7|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|630||||630|186.8|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|Self-pay|Self-pay|630||||630|220.5|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|630||||630|186.8|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|630||||630|186.8|434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|630||||630||434.7|186.8
40840062|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M RBC PER DOSE UP TO 30MCI|30 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|630||||630||434.7|186.8
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|AARP [1000]|AARP [100000]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|AETNA [1015]|AETNA [101529]|1722.5||||1722.5|0|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1722.5||||1722.5|510.72|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BCBS UTHCT [115568]|1722.5||||1722.5|809.58|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1722.5||||1722.5|0|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1722.5||||1722.5|861.25|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1722.5||||1722.5|1085.18|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1722.5||||1722.5|510.72|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|CIGNA [1260]|CIGNA GWH [126023]|1722.5||||1722.5|947.38|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|1722.5||||1722.5|1188.53|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1722.5||||1722.5|861.25|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1722.5||||1722.5|0|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1722.5||||1722.5|510.72|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1722.5||||1722.5|0|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1722.5||||1722.5|510.72|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|1722.5||||1722.5|510.72|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|1722.5||||1722.5|1188.53|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1722.5||||1722.5|510.72|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|Self-pay|Self-pay|1722.5||||1722.5|602.87|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1722.5||||1722.5|510.72|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1722.5||||1722.5|510.72|1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1722.5||||1722.5||1188.53|510.72
40840068|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M MERTIATIDE (MAG3) PER DOSE UP TO 15MCI|15 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1722.5||||1722.5||1188.53|510.72
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|AARP [1000]|AARP [100000]|25||||25||26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25||||25|13.47|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|AETNA [1015]|AETNA [101529]|25||||25|11.03|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25||||25|7.41|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25||||25|13.34|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25||||25|13.34|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|BCBS [1155]|BCBS UTHCT [115568]|25||||25|11.75|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25||||25|0|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25||||25|12.5|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25||||25|15.75|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25||||25|7.41|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25||||25|13.34|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|CIGNA [1260]|CIGNA GWH [126023]|25||||25|13.75|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|25||||25|17.25|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25||||25|16.68|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25||||25|13.34|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25||||25|11.03|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25||||25|7.41|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25||||25|13.34|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25||||25|11.03|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25||||25|7.41|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|25||||25|7.41|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|25||||25|17.25|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25||||25|7.41|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|Self-pay|Self-pay|25||||25|8.75|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25||||25|7.41|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25||||25|7.41|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25||||25||26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25||||25|13.34|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25||||25|13.34|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25||||25||26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25||||25|13.34|26.68|7.41
40840069|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO I-131 SODIUM IODIDE SOLUTION TX PER MCI|1 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25||||25|26.68|26.68|7.41
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|AARP [1000]|AARP [100000]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|AETNA [1015]|AETNA [101529]|50.38||||50.38|22.22|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.38||||50.38|14.94|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|BCBS [1155]|BCBS UTHCT [115568]|50.38||||50.38|23.68|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.38||||50.38|25.19|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.38||||50.38|25.19|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.38||||50.38|31.74|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.38||||50.38|14.94|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|CIGNA [1260]|CIGNA GWH [126023]|50.38||||50.38|27.71|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|50.38||||50.38|34.76|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50.38||||50.38|25.19|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.38||||50.38|22.22|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.38||||50.38|14.94|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.38||||50.38|22.22|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.38||||50.38|14.94|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|50.38||||50.38|14.94|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|50.38||||50.38|34.76|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.38||||50.38|14.94|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|Self-pay|Self-pay|50.38||||50.38|17.63|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50.38||||50.38|14.94|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.38||||50.38|14.94|34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.38||||50.38||34.76|14.94
40840070|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE INFUSION 10 MG/ML 500 MG/50 ML|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.38||||50.38||34.76|14.94
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AARP [1000]|AARP [100000]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AETNA [1015]|AETNA [101529]|384||||384|0|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|384||||384|113.86|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|BCBS [1155]|BCBS UTHCT [115568]|384||||384|180.48|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|384||||384|0|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|384||||384|192|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|384||||384|241.92|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|384||||384|113.86|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|CIGNA [1260]|CIGNA GWH [126023]|384||||384|211.2|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|384||||384|264.96|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|384||||384|192|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|384||||384|0|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|384||||384|113.86|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|384||||384|0|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|384||||384|113.86|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|384||||384|113.86|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|384||||384|264.96|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|384||||384|113.86|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|Self-pay|Self-pay|384||||384|134.4|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|384||||384|113.86|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|384||||384|113.86|264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|384||||384||264.96|113.86
40840076|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M SESTAMIBI (MIBI) PER DOSE|10 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|384||||384||264.96|113.86
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|AARP [1000]|AARP [100000]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|AETNA [1015]|AETNA [101529]|105.4||||105.4|0|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105.4||||105.4|31.25|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|BCBS [1155]|BCBS UTHCT [115568]|105.4||||105.4|49.54|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105.4||||105.4|0|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105.4||||105.4|52.7|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105.4||||105.4|66.4|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105.4||||105.4|31.25|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|CIGNA [1260]|CIGNA GWH [126023]|105.4||||105.4|57.97|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|105.4||||105.4|72.73|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105.4||||105.4|52.7|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105.4||||105.4|0|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105.4||||105.4|31.25|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105.4||||105.4|0|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105.4||||105.4|31.25|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|105.4||||105.4|31.25|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|105.4||||105.4|72.73|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105.4||||105.4|31.25|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|Self-pay|Self-pay|105.4||||105.4|36.89|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105.4||||105.4|31.25|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105.4||||105.4|31.25|72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105.4||||105.4||72.73|31.25
40840080|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M OXIDRONATE PER DOSE UP TO 30 MCI|30 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105.4||||105.4||72.73|31.25
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|AARP [1000]|AARP [100000]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|AETNA [1015]|AETNA [101529]|6216||||6216|0|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6216||||6216|1843.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BCBS UTHCT [115568]|6216||||6216|2921.52|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6216||||6216|0|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6216||||6216|3108|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6216||||6216|3916.08|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6216||||6216|1843.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|CIGNA [1260]|CIGNA GWH [126023]|6216||||6216|3418.8|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|6216||||6216|4289.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6216||||6216|3108|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6216||||6216|0|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6216||||6216|1843.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6216||||6216|0|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6216||||6216|1843.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|6216||||6216|1843.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|6216||||6216|4289.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6216||||6216|1843.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|Self-pay|Self-pay|6216||||6216|2175.6|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6216||||6216|1843.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6216||||6216|1843.04|4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6216||||6216||4289.04|1843.04
40840085|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M BICISATE PER DOSE UP TO 25MCI|25 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6216||||6216||4289.04|1843.04
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|AARP [1000]|AARP [100000]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|AETNA [1015]|AETNA [101529]|450||||450|0|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|450||||450|133.43|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|BCBS [1155]|BCBS UTHCT [115568]|450||||450|211.5|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|450||||450|0|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|450||||450|225|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|450||||450|283.5|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|450||||450|133.43|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|CIGNA [1260]|CIGNA GWH [126023]|450||||450|247.5|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|450||||450|310.5|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|450||||450|225|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|450||||450|0|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|450||||450|133.43|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|450||||450|0|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|450||||450|133.43|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|450||||450|133.43|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|450||||450|310.5|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|450||||450|133.43|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|Self-pay|Self-pay|450||||450|157.5|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|450||||450|133.43|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|450||||450|133.43|310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|450||||450||310.5|133.43
40840090|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 SODIUM IODIDE DX (CAPSULE) PER 100UCI|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|450||||450||310.5|133.43
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|AARP [1000]|AARP [100000]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|AETNA [1015]|AETNA [101529]|22.74||||22.74|10.03|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.74||||22.74|6.74|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|BCBS [1155]|BCBS UTHCT [115568]|22.74||||22.74|10.69|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.74||||22.74|11.37|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.74||||22.74|11.37|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.74||||22.74|14.33|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.74||||22.74|6.74|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|CIGNA [1260]|CIGNA GWH [126023]|22.74||||22.74|12.51|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|22.74||||22.74|15.69|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22.74||||22.74|11.37|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.74||||22.74|10.03|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.74||||22.74|6.74|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.74||||22.74|10.03|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.74||||22.74|6.74|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|22.74||||22.74|6.74|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|22.74||||22.74|15.69|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.74||||22.74|6.74|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|Self-pay|Self-pay|22.74||||22.74|7.96|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22.74||||22.74|6.74|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.74||||22.74|6.74|15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.74||||22.74||15.69|6.74
40840115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|GI COCKTAIL 2:1 RATIO AHS STANDARD SIMPLE|45 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.74||||22.74||15.69|6.74
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|AARP [1000]|AARP [100000]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|AETNA [1015]|AETNA [101529]|9360||||9360|0|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9360||||9360|2775.24|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|BCBS [1155]|BCBS UTHCT [115568]|9360||||9360|4399.2|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9360||||9360|0|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9360||||9360|4680|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9360||||9360|5896.8|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9360||||9360|2775.24|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|CIGNA [1260]|CIGNA GWH [126023]|9360||||9360|5148|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|9360||||9360|6458.4|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9360||||9360|4680|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9360||||9360|0|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9360||||9360|2775.24|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9360||||9360|0|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9360||||9360|2775.24|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|9360||||9360|2775.24|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|9360||||9360|6458.4|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9360||||9360|2775.24|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|Self-pay|Self-pay|9360||||9360|3276|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9360||||9360|2775.24|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9360||||9360|2775.24|6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9360||||9360||6458.4|2775.24
40840133|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO IN-111 LABELED WBC DIAGNOSTIC PER DOSE|1 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9360||||9360||6458.4|2775.24
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|AARP [1000]|AARP [100000]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|AETNA [1015]|AETNA [101529]|0.19||||0.19|0.08|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.19||||0.19|0.06|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|BCBS [1155]|BCBS UTHCT [115568]|0.19||||0.19|0.09|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.19||||0.19|0.1|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.19||||0.19|0.1|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.19||||0.19|0.12|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.19||||0.19|0.06|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|CIGNA [1260]|CIGNA GWH [126023]|0.19||||0.19|0.1|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.19||||0.19|0.13|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.19||||0.19|0.1|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.19||||0.19|0.08|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.19||||0.19|0.06|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.19||||0.19|0.08|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.19||||0.19|0.06|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.19||||0.19|0.06|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.19||||0.19|0.13|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.19||||0.19|0.06|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|Self-pay|Self-pay|0.19||||0.19|0.07|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.19||||0.19|0.06|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.19||||0.19|0.06|0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.19||||0.19||0.13|0.06
40840164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGIC MOUTHWASH PLUS NYSTATIN AHS STANDARD SIMPLE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.19||||0.19||0.13|0.06
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|658.37||||658.37|290.34|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|658.37||||658.37|195.21|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|658.37||||658.37|309.43|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|658.37||||658.37|329.19|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|658.37||||658.37|329.19|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|658.37||||658.37|414.77|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|658.37||||658.37|195.21|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|658.37||||658.37|362.1|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|658.37||||658.37|454.28|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|658.37||||658.37|329.19|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|658.37||||658.37|290.34|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|658.37||||658.37|195.21|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|658.37||||658.37|290.34|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|658.37||||658.37|195.21|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|658.37||||658.37|195.21|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|658.37||||658.37|454.28|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|658.37||||658.37|195.21|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|658.37||||658.37|230.43|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|658.37||||658.37|195.21|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|658.37||||658.37|195.21|454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|658.37||||658.37||454.28|195.21
40840261|ERX|0250 - PHARMACY-GENERAL|VASOPRESSIN 20 UNIT/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|658.37||||658.37||454.28|195.21
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|AARP [1000]|AARP [100000]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|AETNA [1015]|AETNA [101529]|7.17||||7.17|3.16|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.17||||7.17|2.13|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|BCBS [1155]|BCBS UTHCT [115568]|7.17||||7.17|3.37|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.17||||7.17|3.59|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.17||||7.17|3.59|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.17||||7.17|4.52|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.17||||7.17|2.13|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|CIGNA [1260]|CIGNA GWH [126023]|7.17||||7.17|3.94|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.17||||7.17|4.95|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.17||||7.17|3.59|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.17||||7.17|3.16|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.17||||7.17|2.13|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.17||||7.17|3.16|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.17||||7.17|2.13|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.17||||7.17|2.13|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.17||||7.17|4.95|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.17||||7.17|2.13|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|Self-pay|Self-pay|7.17||||7.17|2.51|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.17||||7.17|2.13|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.17||||7.17|2.13|4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.17||||7.17||4.95|2.13
40840262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEXTROMETHORPHAN-GUAIFENESIN 10-100/5ML LIQUID/SYRUP WRAP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.17||||7.17||4.95|2.13
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AARP [1000]|AARP [100000]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.14||||0.14|0.06|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.14||||0.14|0.04|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.14||||0.14|0.07|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.14||||0.14|0.07|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.14||||0.14|0.07|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.14||||0.14|0.09|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.14||||0.14|0.04|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.14||||0.14|0.08|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.14||||0.14|0.1|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.14||||0.14|0.07|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.14||||0.14|0.06|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.14||||0.14|0.04|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.14||||0.14|0.06|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.14||||0.14|0.04|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.14||||0.14|0.04|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.14||||0.14|0.1|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.14||||0.14|0.04|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|Self-pay|Self-pay|0.14||||0.14|0.05|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.14||||0.14|0.04|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.14||||0.14|0.04|0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.14||||0.14||0.1|0.04
40840266|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN WITH MINERALS TABLET WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.14||||0.14||0.1|0.04
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|11.16||||11.16|6.67|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.16||||11.16||7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|11.16||||11.16|7.46|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.16||||11.16|3.31|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.16||||11.16||7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.16||||11.16||7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|11.16||||11.16|5.25|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.16||||11.16|0|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.16||||11.16|5.58|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.16||||11.16|7.03|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.16||||11.16|3.31|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.16||||11.16||7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|11.16||||11.16|6.14|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.16||||11.16|7.7|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.16||||11.16|3.43|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.16||||11.16||7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.16||||11.16|7.46|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.16||||11.16|3.31|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.16||||11.16||7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.16||||11.16|7.46|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.16||||11.16|3.31|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.16||||11.16|3.31|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.16||||11.16|7.7|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.16||||11.16|3.31|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|11.16||||11.16|3.91|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.16||||11.16|3.31|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.16||||11.16|3.31|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.16||||11.16|6.67|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.16||||11.16||7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.16||||11.16||7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.16||||11.16|6.67|7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.16||||11.16||7.7|3.31
40840277|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HYDROMORPHONE 2 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.16||||11.16||7.7|3.31
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AARP [1000]|AARP [100000]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AETNA [1015]|AETNA [101529]|528.55||||528.55|477.91|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|528.55||||528.55|156.72|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS [1155]|BCBS UTHCT [115568]|528.55||||528.55|248.42|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|528.55||||528.55|0|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|528.55||||528.55|264.28|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|528.55||||528.55|332.99|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|528.55||||528.55|156.72|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|CIGNA [1260]|CIGNA GWH [126023]|528.55||||528.55|264.28|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|528.55||||528.55|364.7|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|528.55||||528.55|243.03|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|528.55||||528.55|477.91|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|528.55||||528.55|156.72|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|528.55||||528.55|477.91|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|528.55||||528.55|156.72|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|528.55||||528.55|156.72|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|528.55||||528.55|364.7|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|528.55||||528.55|156.72|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|Self-pay|Self-pay|528.55||||528.55|184.99|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|528.55||||528.55|156.72|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|528.55||||528.55|156.72|477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|528.55||||528.55||477.91|156.72
40840286|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|GLUCAGON 1 MG/ML INJECTION WRAP|1 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|528.55||||528.55||477.91|156.72
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|AARP [1000]|AARP [100000]|6.82||||6.82|4.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|AETNA [1015]|AETNA [101529]|6.82||||6.82|2.64|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.82||||6.82|2.02|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|BCBS [1155]|BCBS UTHCT [115568]|6.82||||6.82|3.21|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.82||||6.82|0|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.82||||6.82|3.41|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.82||||6.82|4.3|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.82||||6.82|2.02|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|CIGNA [1260]|CIGNA GWH [126023]|6.82||||6.82|3.75|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.82||||6.82|4.71|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.82||||6.82|0.15|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.82||||6.82|2.64|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.82||||6.82|2.02|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.82||||6.82|2.64|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.82||||6.82|2.02|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.82||||6.82|2.02|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.82||||6.82|4.71|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.82||||6.82|2.02|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|Self-pay|Self-pay|6.82||||6.82|2.39|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.82||||6.82|2.02|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.82||||6.82|2.02|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.82||||6.82|4.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.82||||6.82|4.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.82||||6.82||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|2.02||||2.02|0.92|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|2.02||||2.02|0.53|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.02||||2.02|0.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|BCBS [1155]|BCBS UTHCT [115568]|2.02||||2.02|0.95|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.02||||2.02|0|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.02||||2.02|1.01|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.02||||2.02|1.27|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.02||||2.02|0.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA GWH [126023]|2.02||||2.02|1.11|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.02||||2.02|1.39|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.02||||2.02|0.15|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.02||||2.02|0.53|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.02||||2.02|0.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.02||||2.02|0.53|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.02||||2.02|0.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.02||||2.02|0.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.02||||2.02|1.39|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.02||||2.02|0.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|Self-pay|Self-pay|2.02||||2.02|0.71|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.02||||2.02|0.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.02||||2.02|0.6|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.02||||2.02|0.92|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.02||||2.02|0.92|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.02||||2.02||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|AARP [1000]|AARP [100000]|4.31||||4.31|2.3|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.31||||4.31||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|AETNA [1015]|AETNA [101529]|4.31||||4.31|1.32|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.31||||4.31|1.28|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.31||||4.31||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.31||||4.31||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|4.31||||4.31|2.03|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.31||||4.31|0|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.31||||4.31|2.16|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.31||||4.31|2.72|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.31||||4.31|1.28|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.31||||4.31||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|4.31||||4.31|2.37|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.31||||4.31|2.97|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.31||||4.31|0.15|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.31||||4.31||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.31||||4.31|1.32|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.31||||4.31|1.28|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.31||||4.31||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.31||||4.31|1.32|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.31||||4.31|1.28|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.31||||4.31|1.28|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.31||||4.31|2.97|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.31||||4.31|1.28|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|Self-pay|Self-pay|4.31||||4.31|1.51|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.31||||4.31|1.28|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.31||||4.31|1.28|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.31||||4.31|2.3|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.31||||4.31||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.31||||4.31||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.31||||4.31|2.3|4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.31||||4.31||4.71|0.15
40840287|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MIDAZOLAM 1 MG/ML PF AND NON-PF INJECTION WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.31||||4.31||4.71|0.15
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AARP [1000]|AARP [100000]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AETNA [1015]|AETNA [101529]|260.09||||260.09|114.7|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|260.09||||260.09|77.12|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS [1155]|BCBS UTHCT [115568]|260.09||||260.09|122.24|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|260.09||||260.09|130.05|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|260.09||||260.09|130.05|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|260.09||||260.09|163.86|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|260.09||||260.09|77.12|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|CIGNA [1260]|CIGNA GWH [126023]|260.09||||260.09|143.05|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|260.09||||260.09|179.46|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|260.09||||260.09|130.05|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|260.09||||260.09|114.7|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|260.09||||260.09|77.12|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|260.09||||260.09|114.7|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|260.09||||260.09|77.12|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|260.09||||260.09|77.12|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|260.09||||260.09|179.46|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|260.09||||260.09|77.12|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|Self-pay|Self-pay|260.09||||260.09|91.03|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|260.09||||260.09|77.12|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|260.09||||260.09|77.12|179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|260.09||||260.09||179.46|77.12
40840292|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEO-POLY-HC OTIC DROPS WRAP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|260.09||||260.09||179.46|77.12
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|AARP [1000]|AARP [100000]|9.49||||9.49|7.6|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|AETNA [1015]|AETNA [101529]|9.49||||9.49|9.49|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.49||||9.49|2.81|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|BCBS [1155]|BCBS UTHCT [115568]|9.49||||9.49|4.46|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.49||||9.49|0|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.49||||9.49|4.75|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.49||||9.49|5.98|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.49||||9.49|2.81|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|CIGNA [1260]|CIGNA GWH [126023]|9.49||||9.49|5.22|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.49||||9.49|6.55|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.49||||9.49|0.9|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.49||||9.49|9.49|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.49||||9.49|2.81|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.49||||9.49|9.49|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.49||||9.49|2.81|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.49||||9.49|2.81|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.49||||9.49|6.55|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.49||||9.49|2.81|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|Self-pay|Self-pay|9.49||||9.49|3.32|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.49||||9.49|2.81|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.49||||9.49|2.81|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.49||||9.49|7.6|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.49||||9.49|7.6|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.49||||9.49||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|AARP [1000]|AARP [100000]|3.91||||3.91|1.52|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|AETNA [1015]|AETNA [101529]|3.91||||3.91|2.18|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.91||||3.91|1.16|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|BCBS [1155]|BCBS UTHCT [115568]|3.91||||3.91|1.84|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.91||||3.91|0|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.91||||3.91|1.96|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.91||||3.91|2.46|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.91||||3.91|1.16|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|CIGNA [1260]|CIGNA GWH [126023]|3.91||||3.91|2.15|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.91||||3.91|2.7|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.91||||3.91|0.9|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.91||||3.91|2.18|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.91||||3.91|1.16|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.91||||3.91|2.18|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.91||||3.91|1.16|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.91||||3.91|1.16|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.91||||3.91|2.7|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.91||||3.91|1.16|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|Self-pay|Self-pay|3.91||||3.91|1.37|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.91||||3.91|1.16|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.91||||3.91|1.16|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.91||||3.91|1.52|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.91||||3.91|1.52|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.91||||3.91||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|AARP [1000]|AARP [100000]|19.72||||19.72|15.2|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|AETNA [1015]|AETNA [101529]|19.72||||19.72|19.72|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.72||||19.72|5.85|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|BCBS [1155]|BCBS UTHCT [115568]|19.72||||19.72|9.27|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.72||||19.72|0|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.72||||19.72|9.86|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.72||||19.72|12.42|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.72||||19.72|5.85|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|CIGNA [1260]|CIGNA GWH [126023]|19.72||||19.72|10.85|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.72||||19.72|13.61|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.72||||19.72|0.9|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.72||||19.72|19.72|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.72||||19.72|5.85|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.72||||19.72|19.72|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.72||||19.72|5.85|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.72||||19.72|5.85|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.72||||19.72|13.61|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.72||||19.72|5.85|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|Self-pay|Self-pay|19.72||||19.72|6.9|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.72||||19.72|5.85|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.72||||19.72|5.85|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.72||||19.72|15.2|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.72||||19.72|15.2|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.72||||19.72||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|AARP [1000]|AARP [100000]|5.86||||5.86|4.56|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.86||||5.86||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|AETNA [1015]|AETNA [101529]|5.86||||5.86|5.86|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.86||||5.86|1.74|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.86||||5.86||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.86||||5.86||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|5.86||||5.86|2.75|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.86||||5.86|0|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.86||||5.86|2.93|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.86||||5.86|3.69|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.86||||5.86|1.74|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.86||||5.86||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|5.86||||5.86|3.22|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.86||||5.86|4.04|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.86||||5.86|0.9|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.86||||5.86||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.86||||5.86|5.86|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.86||||5.86|1.74|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.86||||5.86||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.86||||5.86|5.86|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.86||||5.86|1.74|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.86||||5.86|1.74|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.86||||5.86|4.04|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.86||||5.86|1.74|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|Self-pay|Self-pay|5.86||||5.86|2.05|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.86||||5.86|1.74|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.86||||5.86|1.74|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.86||||5.86|4.56|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.86||||5.86||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.86||||5.86||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.86||||5.86|4.56|19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.86||||5.86||19.72|0.9
408403037|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FENTANYL (PF) 50 MCG/ML INJECTION SOLUTION REPACK WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.86||||5.86||19.72|0.9
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AARP [1000]|AARP [100000]|272.82||||272.82|88.85|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AARP [1000]|AARP [100000]|272.82||||272.82|88.85|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272.82||||272.82|88.63|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|272.82||||272.82|88.63|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AETNA [1015]|AETNA [101529]|272.82||||272.82|210.94|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AETNA [1015]|AETNA [101529]|272.82||||272.82|210.94|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS [1155]|BCBS UTHCT [115568]|272.82||||272.82|128.23|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS [1155]|BCBS UTHCT [115568]|272.82||||272.82|128.23|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272.82||||272.82|0|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|272.82||||272.82|0|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272.82||||272.82|136.41|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|272.82||||272.82|136.41|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272.82||||272.82|171.88|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|272.82||||272.82|171.88|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|CIGNA [1260]|CIGNA GWH [126023]|272.82||||272.82|150.05|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|CIGNA [1260]|CIGNA GWH [126023]|272.82||||272.82|150.05|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|272.82||||272.82|188.25|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|272.82||||272.82|188.25|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|272.82||||272.82|109.29|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|272.82||||272.82|109.29|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272.82||||272.82|210.94|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|272.82||||272.82|210.94|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272.82||||272.82|210.94|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|272.82||||272.82|210.94|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|272.82||||272.82|188.25|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|272.82||||272.82|188.25|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|Self-pay|Self-pay|272.82||||272.82|95.49|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|Self-pay|Self-pay|272.82||||272.82|95.49|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|272.82||||272.82|80.89|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272.82||||272.82|88.85|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|272.82||||272.82|88.85|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272.82||||272.82|88.85|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|272.82||||272.82|88.85|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|272.82||||272.82|87.75|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272.82||||272.82|175.5|210.94|80.89
40840325|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 1 MG/ML IV SYRINGE SIMPLE|1 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|272.82||||272.82|175.5|210.94|80.89
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|AARP [1000]|AARP [100000]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|AETNA [1015]|AETNA [101529]|18.6||||18.6|8.2|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.6||||18.6|5.51|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BCBS UTHCT [115568]|18.6||||18.6|8.74|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.6||||18.6|9.3|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.6||||18.6|9.3|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.6||||18.6|11.72|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.6||||18.6|5.51|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA [1260]|CIGNA GWH [126023]|18.6||||18.6|10.23|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.6||||18.6|12.83|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.6||||18.6|9.3|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.6||||18.6|8.2|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.6||||18.6|5.51|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.6||||18.6|8.2|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.6||||18.6|5.51|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.6||||18.6|5.51|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.6||||18.6|12.83|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.6||||18.6|5.51|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|Self-pay|Self-pay|18.6||||18.6|6.51|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.6||||18.6|5.51|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.6||||18.6|5.51|12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.6||||18.6||12.83|5.51
40840434|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 12 MG/100 ML NS IVPB SIMPLE|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.6||||18.6||12.83|5.51
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|AARP [1000]|AARP [100000]|18.6||||18.6|2.76|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.6||||18.6||12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|AETNA [1015]|AETNA [101529]|18.6||||18.6|3.46|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.6||||18.6|5.51|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.6||||18.6||12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.6||||18.6||12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS [1155]|BCBS UTHCT [115568]|18.6||||18.6|8.74|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.6||||18.6|0|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.6||||18.6|9.3|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.6||||18.6|11.72|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.6||||18.6|5.51|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.6||||18.6||12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|CIGNA [1260]|CIGNA GWH [126023]|18.6||||18.6|10.23|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.6||||18.6|12.83|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.6||||18.6|0.18|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.6||||18.6||12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.6||||18.6|3.46|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.6||||18.6|5.51|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.6||||18.6||12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.6||||18.6|3.46|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.6||||18.6|5.51|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.6||||18.6|5.51|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.6||||18.6|12.83|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.6||||18.6|5.51|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|Self-pay|Self-pay|18.6||||18.6|6.51|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.6||||18.6|5.51|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.6||||18.6|5.51|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.6||||18.6|2.76|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.6||||18.6||12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.6||||18.6||12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.6||||18.6|2.76|12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.6||||18.6||12.83|0.18
40840475|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DEXAMETHASONE 12 MG/50 ML NS IVPB SIMPLE|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.6||||18.6||12.83|0.18
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|AARP [1000]|AARP [100000]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|AETNA [1015]|AETNA [101529]|8||||8|0|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8||||8|2.37|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|BCBS [1155]|BCBS UTHCT [115568]|8||||8|3.76|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8||||8|4|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8||||8|4|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8||||8|5.04|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8||||8|2.37|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|CIGNA [1260]|CIGNA GWH [126023]|8||||8|4.4|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|GROUP PENSION ADMIN [1450]|GPA [145000]|8||||8|5.52|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8||||8|12.5|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8||||8|0|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8||||8|2.37|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8||||8|0|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8||||8|2.37|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|PENDING SSI [1616]|PENDING SSI RCA [161601]|8||||8|2.37|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|PHCS [1780]|PHCS MULTIPLAN [178000]|8||||8|5.52|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8||||8|2.37|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|Self-pay|Self-pay|8||||8|2.8|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8||||8|2.37|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8||||8|2.37|12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8||||8||12.5|2.37
40840556|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TC99M NON-HEU ADD-ON FOR STUDY DOSE|1 Dose|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8||||8||12.5|2.37
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|AARP [1000]|AARP [100000]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|AETNA [1015]|AETNA [101529]|66000||||66000|29106|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66000||||66000|19569|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|BCBS [1155]|BCBS UTHCT [115568]|66000||||66000|31020|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66000||||66000|20395.46|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66000||||66000|33000|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66000||||66000|41580|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66000||||66000|19569|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|CIGNA [1260]|CIGNA GWH [126023]|66000||||66000|36300|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|66000||||66000|45540|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66000||||66000|21747.05|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66000||||66000|29106|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66000||||66000|19569|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66000||||66000|29106|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66000||||66000|19569|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|66000||||66000|19569|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|66000||||66000|45540|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66000||||66000|19569|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|Self-pay|Self-pay|66000||||66000|23100|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66000||||66000|19569|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66000||||66000|19569|45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66000||||66000||45540|19569
40840557|ERX|0344 - NUCLEAR MEDICINE-THERAPEUTIC RADIOPHARMACEU|NM ISO Y-90 SIR-SPHERES RESIN MICROSPHERES PER DOSE|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66000||||66000||45540|19569
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|AARP [1000]|AARP [100000]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|AETNA [1015]|AETNA [101529]|44.64||||44.64|19.69|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.64||||44.64|13.24|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|BCBS [1155]|BCBS UTHCT [115568]|44.64||||44.64|20.98|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.64||||44.64|22.32|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.64||||44.64|22.32|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.64||||44.64|28.12|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.64||||44.64|13.24|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|CIGNA [1260]|CIGNA GWH [126023]|44.64||||44.64|24.55|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|44.64||||44.64|30.8|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|44.64||||44.64|22.32|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.64||||44.64|19.69|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.64||||44.64|13.24|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.64||||44.64|19.69|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.64||||44.64|13.24|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|44.64||||44.64|13.24|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|44.64||||44.64|30.8|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.64||||44.64|13.24|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|Self-pay|Self-pay|44.64||||44.64|15.62|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|44.64||||44.64|13.24|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.64||||44.64|13.24|30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.64||||44.64||30.8|13.24
40840652|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 10 MCG/ML IN SODIUM CHLORIDE 0.9% PCA (1 HOUR LOCKOUT)|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.64||||44.64||30.8|13.24
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|AARP [1000]|AARP [100000]|3.1||||3.1|3.1|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.1||||3.1||3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|AETNA [1015]|AETNA [101529]|3.1||||3.1|3.1|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.1||||3.1|0.92|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.1||||3.1||3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.1||||3.1||3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BCBS UTHCT [115568]|3.1||||3.1|1.46|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.1||||3.1|0|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.1||||3.1|1.55|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.1||||3.1|1.95|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.1||||3.1|0.92|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.1||||3.1||3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA [1260]|CIGNA GWH [126023]|3.1||||3.1|1.71|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.1||||3.1|2.14|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.1||||3.1|0.11|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.1||||3.1||3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.1||||3.1|3.1|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.1||||3.1|0.92|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.1||||3.1||3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.1||||3.1|3.1|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.1||||3.1|0.92|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.1||||3.1|0.92|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.1||||3.1|2.14|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.1||||3.1|0.92|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|Self-pay|Self-pay|3.1||||3.1|1.08|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.1||||3.1|0.92|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.1||||3.1|0.92|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.1||||3.1|3.1|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.1||||3.1||3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.1||||3.1||3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.1||||3.1|3.1|3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.1||||3.1||3.1|0.11
40840867|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONDANSETRON 16 MG/100 ML NS IVPB SIMPLE|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.1||||3.1||3.1|0.11
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|AARP [1000]|AARP [100000]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|AETNA [1015]|AETNA [101529]|16.37||||16.37|7.22|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.37||||16.37|4.85|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BCBS UTHCT [115568]|16.37||||16.37|7.69|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.37||||16.37|8.19|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.37||||16.37|8.19|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.37||||16.37|10.31|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.37||||16.37|4.85|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|CIGNA [1260]|CIGNA GWH [126023]|16.37||||16.37|9|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.37||||16.37|11.3|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.37||||16.37|8.19|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.37||||16.37|7.22|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.37||||16.37|4.85|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.37||||16.37|7.22|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.37||||16.37|4.85|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.37||||16.37|4.85|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.37||||16.37|11.3|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.37||||16.37|4.85|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|Self-pay|Self-pay|16.37||||16.37|5.73|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.37||||16.37|4.85|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.37||||16.37|4.85|11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.37||||16.37||11.3|4.85
40840869|ERX|0250 - PHARMACY-GENERAL|DEXAMETHASONE 20 MG/100 ML NS IVPB SIMPLE|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.37||||16.37||11.3|4.85
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AARP [1000]|AARP [100000]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AETNA [1015]|AETNA [101529]|0.53||||0.53|0.23|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.53||||0.53|0.16|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.53||||0.53|0.25|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.53||||0.53|0.27|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.53||||0.53|0.27|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.53||||0.53|0.33|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.53||||0.53|0.16|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.53||||0.53|0.29|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.53||||0.53|0.37|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.53||||0.53|0.27|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.53||||0.53|0.23|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.53||||0.53|0.16|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.53||||0.53|0.23|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.53||||0.53|0.16|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.53||||0.53|0.16|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.53||||0.53|0.37|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.53||||0.53|0.16|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|Self-pay|Self-pay|0.53||||0.53|0.19|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.53||||0.53|0.16|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.53||||0.53|0.16|0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.53||||0.53||0.37|0.16
40840895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRENATAL VITAMIN WRAP|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.53||||0.53||0.37|0.16
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|AARP [1000]|AARP [100000]|38.75||||38.75|17.44|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.75||||38.75||26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|AETNA [1015]|AETNA [101529]|38.75||||38.75|1.92|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.75||||38.75|11.49|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.75||||38.75||26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.75||||38.75||26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS [1155]|BCBS UTHCT [115568]|38.75||||38.75|18.21|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.75||||38.75|0|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.75||||38.75|19.38|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.75||||38.75|24.41|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.75||||38.75|11.49|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.75||||38.75||26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|CIGNA [1260]|CIGNA GWH [126023]|38.75||||38.75|21.31|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|38.75||||38.75|26.74|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|38.75||||38.75|0.11|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.75||||38.75||26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.75||||38.75|1.92|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.75||||38.75|11.49|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.75||||38.75||26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.75||||38.75|1.92|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.75||||38.75|11.49|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|38.75||||38.75|11.49|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|38.75||||38.75|26.74|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.75||||38.75|11.49|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|Self-pay|Self-pay|38.75||||38.75|13.56|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|38.75||||38.75|11.49|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.75||||38.75|11.49|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.75||||38.75|17.44|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|38.75||||38.75||26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|38.75||||38.75||26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.75||||38.75|17.44|26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.75||||38.75||26.74|0.11
40840902|ERX|0250 - PHARMACY-GENERAL|ONDANSETRON 8 MG/50 ML NS IVPB SIMPLE|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.75||||38.75||26.74|0.11
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AARP [1000]|AARP [100000]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AETNA [1015]|AETNA [101529]|0.44||||0.44|0.19|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.44||||0.44|0.13|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.44||||0.44|0.21|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.44||||0.44|0.22|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.44||||0.44|0.22|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.44||||0.44|0.28|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.44||||0.44|0.13|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.44||||0.44|0.24|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.44||||0.44|0.3|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.44||||0.44|0.22|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.44||||0.44|0.19|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.44||||0.44|0.13|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.44||||0.44|0.19|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.44||||0.44|0.13|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.44||||0.44|0.13|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.44||||0.44|0.3|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.44||||0.44|0.13|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|Self-pay|Self-pay|0.44||||0.44|0.15|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.44||||0.44|0.13|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.44||||0.44|0.13|0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.44||||0.44||0.3|0.13
40840962|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID (RENAL VITAMIN WRAP)|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.44||||0.44||0.3|0.13
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|AARP [1000]|AARP [100000]|17.92||||17.92|13|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.92||||17.92||13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|AETNA [1015]|AETNA [101529]|17.92||||17.92|7.2|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.92||||17.92|5.31|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.92||||17.92||13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.92||||17.92||13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|17.92||||17.92|8.42|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.92||||17.92|0|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.92||||17.92|8.96|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.92||||17.92|11.29|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.92||||17.92|5.31|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.92||||17.92||13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|17.92||||17.92|9.86|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.92||||17.92|12.36|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.92||||17.92|0.81|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.92||||17.92||13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.92||||17.92|7.2|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.92||||17.92|5.31|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.92||||17.92||13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.92||||17.92|7.2|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.92||||17.92|5.31|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.92||||17.92|5.31|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.92||||17.92|12.36|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.92||||17.92|5.31|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|Self-pay|Self-pay|17.92||||17.92|6.27|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.92||||17.92|5.31|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.92||||17.92|5.31|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.92||||17.92|13|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.92||||17.92||13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.92||||17.92||13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.92||||17.92|13|13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.92||||17.92||13|0.81
40841321|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FUROSEMIDE 10 MG/ML INFUSION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.92||||17.92||13|0.81
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AARP [1000]|AARP [100000]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AARP [1000]|AARP [100000]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AARP [1000]|AARP [100000]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AETNA [1015]|AETNA [101529]|0.16||||0.16|0.07|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AETNA [1015]|AETNA [101529]|0.16||||0.16|0.07|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AETNA [1015]|AETNA [101529]|0.16||||0.16|0.07|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.16||||0.16|0.1|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.16||||0.16|0.1|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.16||||0.16|0.1|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.16||||0.16|0.09|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.16||||0.16|0.09|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.16||||0.16|0.09|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.16||||0.16|0.11|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.16||||0.16|0.11|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.16||||0.16|0.11|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.16||||0.16|0.08|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.16||||0.16|0.07|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.16||||0.16|0.07|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.16||||0.16|0.07|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.16||||0.16|0.07|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.16||||0.16|0.07|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.16||||0.16|0.07|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.16||||0.16|0.11|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.16||||0.16|0.11|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.16||||0.16|0.11|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|Self-pay|Self-pay|0.16||||0.16|0.06|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|Self-pay|Self-pay|0.16||||0.16|0.06|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|Self-pay|Self-pay|0.16||||0.16|0.06|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.16||||0.16|0.05|0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.16||||0.16||0.11|0.05
40841423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MULTIVITAMIN ORAL LIQUID WRAP|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.16||||0.16||0.11|0.05
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|0.11||||0.11|0.05|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.11||||0.11|0.03|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.11||||0.11|0.05|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.11||||0.11|0.06|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.11||||0.11|0.06|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.11||||0.11|0.07|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.11||||0.11|0.03|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.11||||0.11|0.06|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.11||||0.11|0.08|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.11||||0.11|0.06|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.11||||0.11|0.05|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.11||||0.11|0.03|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.11||||0.11|0.05|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.11||||0.11|0.03|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.11||||0.11|0.03|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.11||||0.11|0.08|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.11||||0.11|0.03|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|Self-pay|Self-pay|0.11||||0.11|0.04|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.11||||0.11|0.03|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.11||||0.11|0.03|0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.11||||0.11||0.08|0.03
40841472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FUROSEMIDE 10 MG SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.11||||0.11||0.08|0.03
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|1.15||||1.15|0.51|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.15||||1.15|0.34|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|1.15||||1.15|0.54|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.15||||1.15|0.58|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.15||||1.15|0.58|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.15||||1.15|0.72|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.15||||1.15|0.34|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|1.15||||1.15|0.63|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.15||||1.15|0.79|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.15||||1.15|0.58|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.15||||1.15|0.51|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.15||||1.15|0.34|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.15||||1.15|0.51|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.15||||1.15|0.34|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.15||||1.15|0.34|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.15||||1.15|0.79|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.15||||1.15|0.34|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|Self-pay|Self-pay|1.15||||1.15|0.4|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.15||||1.15|0.34|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.15||||1.15|0.34|0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.15||||1.15||0.79|0.34
40841473|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALLOPURINOL 150 MG SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.15||||1.15||0.79|0.34
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|0.67||||0.67|0.3|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.67||||0.67|0.2|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.67||||0.67|0.31|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.67||||0.67|0.34|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.67||||0.67|0.34|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.67||||0.67|0.42|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.67||||0.67|0.2|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.67||||0.67|0.37|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.67||||0.67|0.46|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.67||||0.67|0.34|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.67||||0.67|0.3|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.67||||0.67|0.2|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.67||||0.67|0.3|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.67||||0.67|0.2|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.67||||0.67|0.2|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.67||||0.67|0.46|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.67||||0.67|0.2|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|Self-pay|Self-pay|0.67||||0.67|0.23|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.67||||0.67|0.2|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.67||||0.67|0.2|0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.67||||0.67||0.46|0.2
40841474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 12.5 MG SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.67||||0.67||0.46|0.2
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|AARP [1000]|AARP [100000]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|AETNA [1015]|AETNA [101529]|0.17||||0.17|0.07|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.17||||0.17|0.05|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.17||||0.17|0.08|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.17||||0.17|0.09|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.17||||0.17|0.09|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.17||||0.17|0.11|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.17||||0.17|0.05|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.17||||0.17|0.09|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.17||||0.17|0.12|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.17||||0.17|0.09|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.17||||0.17|0.07|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.17||||0.17|0.05|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.17||||0.17|0.07|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.17||||0.17|0.05|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.17||||0.17|0.05|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.17||||0.17|0.12|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.17||||0.17|0.05|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|Self-pay|Self-pay|0.17||||0.17|0.06|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.17||||0.17|0.05|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.17||||0.17|0.05|0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.17||||0.17||0.12|0.05
40841475|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 2.5 MG SPLIT TABLET|2 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.17||||0.17||0.12|0.05
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|AARP [1000]|AARP [100000]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|AETNA [1015]|AETNA [101529]|5.94||||5.94|2.62|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.94||||5.94|1.76|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BCBS UTHCT [115568]|5.94||||5.94|2.79|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.94||||5.94|2.97|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.94||||5.94|2.97|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.94||||5.94|3.74|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.94||||5.94|1.76|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|CIGNA [1260]|CIGNA GWH [126023]|5.94||||5.94|3.27|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.94||||5.94|4.1|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.94||||5.94|2.97|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.94||||5.94|2.62|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.94||||5.94|1.76|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.94||||5.94|2.62|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.94||||5.94|1.76|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.94||||5.94|1.76|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.94||||5.94|4.1|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.94||||5.94|1.76|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|Self-pay|Self-pay|5.94||||5.94|2.08|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.94||||5.94|1.76|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.94||||5.94|1.76|4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.94||||5.94||4.1|1.76
40841476|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORTHALIDONE 12.5 MG SPLIT TABLET|2 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.94||||5.94||4.1|1.76
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|2.25||||2.25|0.99|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.25||||2.25|0.67|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|2.25||||2.25|1.06|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.25||||2.25|1.13|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.25||||2.25|1.13|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.25||||2.25|1.42|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.25||||2.25|0.67|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|2.25||||2.25|1.24|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.25||||2.25|1.55|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.25||||2.25|1.13|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.25||||2.25|0.99|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.25||||2.25|0.67|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.25||||2.25|0.99|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.25||||2.25|0.67|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.25||||2.25|0.67|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.25||||2.25|1.55|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.25||||2.25|0.67|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|Self-pay|Self-pay|2.25||||2.25|0.79|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.25||||2.25|0.67|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.25||||2.25|0.67|1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.25||||2.25||1.55|0.67
40841477|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 62.5 MCG (0.0625 MG) SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.25||||2.25||1.55|0.67
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|0.63||||0.63|0.28|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.63||||0.63|0.19|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.63||||0.63|0.3|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.63||||0.63|0.32|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.63||||0.63|0.32|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.63||||0.63|0.4|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.63||||0.63|0.19|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.63||||0.63|0.35|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.63||||0.63|0.43|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.63||||0.63|0.32|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.63||||0.63|0.28|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.63||||0.63|0.19|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.63||||0.63|0.28|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.63||||0.63|0.19|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.63||||0.63|0.19|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.63||||0.63|0.43|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.63||||0.63|0.19|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|Self-pay|Self-pay|0.63||||0.63|0.22|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.63||||0.63|0.19|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.63||||0.63|0.19|0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.63||||0.63||0.43|0.19
40841478|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 1 MG SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.63||||0.63||0.43|0.19
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|AARP [1000]|AARP [100000]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|AETNA [1015]|AETNA [101529]|2.62||||2.62|1.16|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.62||||2.62|0.78|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BCBS UTHCT [115568]|2.62||||2.62|1.23|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.62||||2.62|1.31|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.62||||2.62|1.31|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.62||||2.62|1.65|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.62||||2.62|0.78|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|CIGNA [1260]|CIGNA GWH [126023]|2.62||||2.62|1.44|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.62||||2.62|1.81|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.62||||2.62|1.31|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.62||||2.62|1.16|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.62||||2.62|0.78|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.62||||2.62|1.16|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.62||||2.62|0.78|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.62||||2.62|0.78|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.62||||2.62|1.81|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.62||||2.62|0.78|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|Self-pay|Self-pay|2.62||||2.62|0.92|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.62||||2.62|0.78|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.62||||2.62|0.78|1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.62||||2.62||1.81|0.78
40841479|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUDROCORTISONE 0.05 MG SPLIT TABLET|2 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.62||||2.62||1.81|0.78
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|0.18||||0.18|0.08|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.18||||0.18|0.05|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.18||||0.18|0.08|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.18||||0.18|0.09|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.18||||0.18|0.09|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.18||||0.18|0.11|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.18||||0.18|0.05|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.18||||0.18|0.1|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.18||||0.18|0.12|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.18||||0.18|0.09|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.18||||0.18|0.08|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.18||||0.18|0.05|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.18||||0.18|0.08|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.18||||0.18|0.05|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.18||||0.18|0.05|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.18||||0.18|0.12|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.18||||0.18|0.05|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|Self-pay|Self-pay|0.18||||0.18|0.06|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.18||||0.18|0.05|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.18||||0.18|0.05|0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.18||||0.18||0.12|0.05
40841480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MAGNESIUM OXIDE 200 MG (120.65 MG MAGNESIUM) SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.18||||0.18||0.12|0.05
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|0.71||||0.71|0.31|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.71||||0.71|0.21|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.71||||0.71|0.33|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.71||||0.71|0.36|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.71||||0.71|0.36|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.71||||0.71|0.45|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.71||||0.71|0.21|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.71||||0.71|0.39|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.71||||0.71|0.49|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.71||||0.71|0.36|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.71||||0.71|0.31|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.71||||0.71|0.21|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.71||||0.71|0.31|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.71||||0.71|0.21|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.71||||0.71|0.21|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.71||||0.71|0.49|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.71||||0.71|0.21|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|Self-pay|Self-pay|0.71||||0.71|0.25|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.71||||0.71|0.21|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.71||||0.71|0.21|0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.71||||0.71||0.49|0.21
40841481|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 2.5 MG SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.71||||0.71||0.49|0.21
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|AARP [1000]|AARP [100000]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|AETNA [1015]|AETNA [101529]|1.13||||1.13|0.5|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.13||||1.13|0.34|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BCBS UTHCT [115568]|1.13||||1.13|0.53|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.13||||1.13|0.57|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.13||||1.13|0.57|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.13||||1.13|0.71|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.13||||1.13|0.34|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|CIGNA [1260]|CIGNA GWH [126023]|1.13||||1.13|0.62|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.13||||1.13|0.78|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.13||||1.13|0.57|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.13||||1.13|0.5|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.13||||1.13|0.34|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.13||||1.13|0.5|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.13||||1.13|0.34|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.13||||1.13|0.34|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.13||||1.13|0.78|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.13||||1.13|0.34|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|Self-pay|Self-pay|1.13||||1.13|0.4|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.13||||1.13|0.34|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.13||||1.13|0.34|0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.13||||1.13||0.78|0.34
40841482|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPAFENONE 75 MG SPLIT TABLET|2 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.13||||1.13||0.78|0.34
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|18.67||||18.67|8.23|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.67||||18.67|5.54|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|18.67||||18.67|8.77|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.67||||18.67|9.34|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.67||||18.67|9.34|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.67||||18.67|11.76|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.67||||18.67|5.54|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|18.67||||18.67|10.27|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|18.67||||18.67|12.88|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.67||||18.67|9.34|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.67||||18.67|8.23|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.67||||18.67|5.54|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.67||||18.67|8.23|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.67||||18.67|5.54|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.67||||18.67|5.54|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|18.67||||18.67|12.88|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.67||||18.67|5.54|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|Self-pay|Self-pay|18.67||||18.67|6.53|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.67||||18.67|5.54|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.67||||18.67|5.54|12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.67||||18.67||12.88|5.54
40841485|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ROFLUMILAST 250 MCG SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.67||||18.67||12.88|5.54
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|AARP [1000]|AARP [100000]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|AETNA [1015]|AETNA [101529]|0.57||||0.57|0.25|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.57||||0.57|0.17|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.57||||0.57|0.27|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.57||||0.57|0.29|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.57||||0.57|0.29|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.57||||0.57|0.36|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.57||||0.57|0.17|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.57||||0.57|0.31|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.57||||0.57|0.39|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.57||||0.57|0.29|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.57||||0.57|0.25|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.57||||0.57|0.17|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.57||||0.57|0.25|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.57||||0.57|0.17|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.57||||0.57|0.17|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.57||||0.57|0.39|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.57||||0.57|0.17|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|Self-pay|Self-pay|0.57||||0.57|0.2|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.57||||0.57|0.17|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.57||||0.57|0.17|0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.57||||0.57||0.39|0.17
40841486|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 75 MG SPLIT TABLET|1 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.57||||0.57||0.39|0.17
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|AARP [1000]|AARP [100000]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|AETNA [1015]|AETNA [101529]|0.41||||0.41|0.18|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.41||||0.41|0.12|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BCBS UTHCT [115568]|0.41||||0.41|0.19|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.41||||0.41|0.21|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.41||||0.41|0.21|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.41||||0.41|0.26|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.41||||0.41|0.12|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|CIGNA [1260]|CIGNA GWH [126023]|0.41||||0.41|0.23|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.41||||0.41|0.28|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.41||||0.41|0.21|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.41||||0.41|0.18|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.41||||0.41|0.12|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.41||||0.41|0.18|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.41||||0.41|0.12|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.41||||0.41|0.12|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.41||||0.41|0.28|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.41||||0.41|0.12|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|Self-pay|Self-pay|0.41||||0.41|0.14|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.41||||0.41|0.12|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.41||||0.41|0.12|0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.41||||0.41||0.28|0.12
40841487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 25 MG SPLIT TABLET|2 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.41||||0.41||0.28|0.12
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|AARP [1000]|AARP [100000]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|AETNA [1015]|AETNA [101529]|9.73||||9.73|4.29|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.73||||9.73|2.88|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|BCBS [1155]|BCBS UTHCT [115568]|9.73||||9.73|4.57|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.73||||9.73|4.87|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.73||||9.73|4.87|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.73||||9.73|6.13|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.73||||9.73|2.88|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|CIGNA [1260]|CIGNA GWH [126023]|9.73||||9.73|5.35|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.73||||9.73|6.71|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.73||||9.73|4.87|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.73||||9.73|4.29|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.73||||9.73|2.88|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.73||||9.73|4.29|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.73||||9.73|2.88|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.73||||9.73|2.88|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.73||||9.73|6.71|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.73||||9.73|2.88|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|Self-pay|Self-pay|9.73||||9.73|3.41|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.73||||9.73|2.88|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.73||||9.73|2.88|6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.73||||9.73||6.71|2.88
40841488|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 500 MCG SPLIT TABLET|2 split tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.73||||9.73||6.71|2.88
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AARP [1000]|AARP [100000]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AETNA [1015]|AETNA [101529]|99.2||||99.2|43.75|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|99.2||||99.2|29.41|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BCBS UTHCT [115568]|99.2||||99.2|46.62|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|99.2||||99.2|49.6|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|99.2||||99.2|49.6|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|99.2||||99.2|62.5|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|99.2||||99.2|29.41|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|CIGNA [1260]|CIGNA GWH [126023]|99.2||||99.2|54.56|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|99.2||||99.2|68.45|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|99.2||||99.2|49.6|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|99.2||||99.2|43.75|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|99.2||||99.2|29.41|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|99.2||||99.2|43.75|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|99.2||||99.2|29.41|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|99.2||||99.2|29.41|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|99.2||||99.2|68.45|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|99.2||||99.2|29.41|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|Self-pay|Self-pay|99.2||||99.2|34.72|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|99.2||||99.2|29.41|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|99.2||||99.2|29.41|68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|99.2||||99.2||68.45|29.41
40841540|ERX|0250 - PHARMACY-GENERAL|EPINEPHRINE HCL 16 MG/250 ML (64 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|99.2||||99.2||68.45|29.41
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|AARP [1000]|AARP [100000]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|AETNA [1015]|AETNA [101529]|157.48||||157.48|69.45|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|157.48||||157.48|46.69|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|BCBS [1155]|BCBS UTHCT [115568]|157.48||||157.48|74.02|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|157.48||||157.48|78.74|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|157.48||||157.48|78.74|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|157.48||||157.48|99.21|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|157.48||||157.48|46.69|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|CIGNA [1260]|CIGNA GWH [126023]|157.48||||157.48|86.61|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|157.48||||157.48|108.66|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|157.48||||157.48|78.74|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|157.48||||157.48|69.45|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|157.48||||157.48|46.69|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|157.48||||157.48|69.45|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|157.48||||157.48|46.69|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|157.48||||157.48|46.69|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|157.48||||157.48|108.66|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|157.48||||157.48|46.69|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|Self-pay|Self-pay|157.48||||157.48|55.12|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|157.48||||157.48|46.69|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|157.48||||157.48|46.69|108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|157.48||||157.48||108.66|46.69
40841790|ERX|0250 - PHARMACY-GENERAL|FENTANYL (PF) 20 MCG/ML IN 0.9 % SODIUM CHLORIDE INTRAVENOUS SIMPLE|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|157.48||||157.48||108.66|46.69
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AARP [1000]|AARP [100000]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AETNA [1015]|AETNA [101529]|8.22||||8.22|3.63|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.22||||8.22|2.44|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS [1155]|BCBS UTHCT [115568]|8.22||||8.22|3.86|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.22||||8.22|4.11|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.22||||8.22|4.11|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.22||||8.22|5.18|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.22||||8.22|2.44|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|CIGNA [1260]|CIGNA GWH [126023]|8.22||||8.22|4.52|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.22||||8.22|5.67|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.22||||8.22|4.11|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.22||||8.22|3.63|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.22||||8.22|2.44|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.22||||8.22|3.63|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.22||||8.22|2.44|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.22||||8.22|2.44|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.22||||8.22|5.67|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.22||||8.22|2.44|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|Self-pay|Self-pay|8.22||||8.22|2.88|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.22||||8.22|2.44|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.22||||8.22|2.44|5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.22||||8.22||5.67|2.44
40842017|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VANCOMYCIN 25 MG/ML ORAL SOLUTION SIMPLE|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.22||||8.22||5.67|2.44
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|AARP [1000]|AARP [100000]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|AETNA [1015]|AETNA [101529]|102.61||||102.61|45.25|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102.61||||102.61|30.42|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|102.61||||102.61|48.23|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102.61||||102.61|51.31|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102.61||||102.61|51.31|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102.61||||102.61|64.64|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102.61||||102.61|30.42|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|102.61||||102.61|56.44|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|102.61||||102.61|70.8|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102.61||||102.61|51.31|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102.61||||102.61|45.25|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102.61||||102.61|30.42|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102.61||||102.61|45.25|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102.61||||102.61|30.42|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|102.61||||102.61|30.42|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|102.61||||102.61|70.8|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102.61||||102.61|30.42|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|Self-pay|Self-pay|102.61||||102.61|35.91|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102.61||||102.61|30.42|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102.61||||102.61|30.42|70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102.61||||102.61||70.8|30.42
4084400355|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUMETANIDE 25 MG/100 ML (0.25 MG/ML) INFUSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102.61||||102.61||70.8|30.42
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|5.37||||5.37|3.22|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|5.37||||5.37|3.22|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|5.37||||5.37|3.07|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|5.37||||5.37|3.07|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BCBS UTHCT [115568]|5.37||||5.37|2.52|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BCBS UTHCT [115568]|5.37||||5.37|2.52|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.37||||5.37|0|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.37||||5.37|0|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.37||||5.37|2.69|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.37||||5.37|2.69|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.37||||5.37|3.38|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.37||||5.37|3.38|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA GWH [126023]|5.37||||5.37|2.95|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA GWH [126023]|5.37||||5.37|2.95|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.37||||5.37|3.71|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.37||||5.37|3.71|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.37||||5.37|0.79|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.37||||5.37|0.79|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.37||||5.37|3.07|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.37||||5.37|3.07|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.37||||5.37|3.07|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.37||||5.37|3.07|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.37||||5.37|3.71|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.37||||5.37|3.71|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|Self-pay|Self-pay|5.37||||5.37|1.88|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|Self-pay|Self-pay|5.37||||5.37|1.88|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.37||||5.37|1.59|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.37||||5.37|3.22|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.37||||5.37|3.22|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.37||||5.37|3.22|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.37||||5.37|3.22|3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.37||||5.37||3.71|0.79
4084720|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MAGNESIUM SULFATE 4 MEQ/ML (50 %) INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.37||||5.37||3.71|0.79
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AARP [1000]|AARP [100000]|9.59||||9.59|7.7|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.59||||9.59||9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AETNA [1015]|AETNA [101529]|9.59||||9.59|9.59|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.59||||9.59|2.84|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.59||||9.59||9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.59||||9.59||9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|9.59||||9.59|4.51|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.59||||9.59|0|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.59||||9.59|4.8|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.59||||9.59|6.04|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.59||||9.59|2.84|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.59||||9.59||9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|9.59||||9.59|5.27|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.59||||9.59|6.62|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.59||||9.59|6.68|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.59||||9.59||9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.59||||9.59|9.59|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.59||||9.59|2.84|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.59||||9.59||9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.59||||9.59|9.59|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.59||||9.59|2.84|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.59||||9.59|2.84|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.59||||9.59|6.62|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.59||||9.59|2.84|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|Self-pay|Self-pay|9.59||||9.59|3.36|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.59||||9.59|2.84|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.59||||9.59|2.84|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.59||||9.59|7.7|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.59||||9.59||9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.59||||9.59||9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.59||||9.59|7.7|9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.59||||9.59||9.59|2.84
4084904|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEPERIDINE (PF) 50 MG/ML INJECTION WRAP|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.59||||9.59||9.59|2.84
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AARP [1000]|AARP [100000]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AETNA [1015]|AETNA [101529]|3.46||||3.46|2.95|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.46||||3.46|1.03|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS [1155]|BCBS UTHCT [115568]|3.46||||3.46|1.63|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.46||||3.46|0|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.46||||3.46|1.73|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.46||||3.46|2.18|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.46||||3.46|1.03|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|CIGNA [1260]|CIGNA GWH [126023]|3.46||||3.46|1.9|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.46||||3.46|2.39|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.46||||3.46|1.35|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.46||||3.46|2.95|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.46||||3.46|1.03|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.46||||3.46|2.95|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.46||||3.46|1.03|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.46||||3.46|1.03|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.46||||3.46|2.39|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.46||||3.46|1.03|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|Self-pay|Self-pay|3.46||||3.46|1.21|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.46||||3.46|1.03|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.46||||3.46|1.03|2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.46||||3.46||2.95|1.03
4085002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METOCLOPRAMIDE 5 MG/ML INJECTION WRAP|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.46||||3.46||2.95|1.03
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AARP [1000]|AARP [100000]|7.05||||7.05|5.25|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.05||||7.05||7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AETNA [1015]|AETNA [101529]|7.05||||7.05|7.05|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.05||||7.05|2.09|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.05||||7.05||7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.05||||7.05||7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|7.05||||7.05|3.31|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.05||||7.05|0|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.05||||7.05|3.53|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.05||||7.05|4.44|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.05||||7.05|2.09|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.05||||7.05||7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|7.05||||7.05|3.88|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.05||||7.05|4.86|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.05||||7.05|3.94|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.05||||7.05||7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.05||||7.05|7.05|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.05||||7.05|2.09|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.05||||7.05||7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.05||||7.05|7.05|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.05||||7.05|2.09|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.05||||7.05|2.09|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.05||||7.05|4.86|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.05||||7.05|2.09|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|Self-pay|Self-pay|7.05||||7.05|2.47|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.05||||7.05|2.09|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.05||||7.05|2.09|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.05||||7.05|5.25|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.05||||7.05||7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.05||||7.05||7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.05||||7.05|5.25|7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.05||||7.05||7.05|2.09
4085172|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 4 MG/ML INJECTION WRAP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.05||||7.05||7.05|2.09
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AARP [1000]|AARP [100000]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AETNA [1015]|AETNA [101529]|1.22||||1.22|0.54|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.22||||1.22|0.36|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.22||||1.22|0.57|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.22||||1.22|0.61|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.22||||1.22|0.61|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.22||||1.22|0.77|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.22||||1.22|0.36|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.22||||1.22|0.67|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.22||||1.22|0.84|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.22||||1.22|0.61|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.22||||1.22|0.54|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.22||||1.22|0.36|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.22||||1.22|0.54|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.22||||1.22|0.36|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.22||||1.22|0.36|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.22||||1.22|0.84|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.22||||1.22|0.36|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|Self-pay|Self-pay|1.22||||1.22|0.43|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.22||||1.22|0.36|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.22||||1.22|0.36|0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.22||||1.22||0.84|0.36
4085538|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN ER 500 MG CAPSULE/TABLET,EXTENDED RELEASE WRAP|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.22||||1.22||0.84|0.36
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AARP [1000]|AARP [100000]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AETNA [1015]|AETNA [101529]|59.46||||59.46|44.16|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.46||||59.46|17.63|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|BCBS [1155]|BCBS UTHCT [115568]|59.46||||59.46|27.95|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.46||||59.46|0|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.46||||59.46|29.73|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.46||||59.46|37.46|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.46||||59.46|17.63|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|CIGNA [1260]|CIGNA GWH [126023]|59.46||||59.46|32.7|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.46||||59.46|41.03|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|59.46||||59.46|29.73|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.46||||59.46|44.16|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.46||||59.46|17.63|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.46||||59.46|44.16|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.46||||59.46|17.63|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|59.46||||59.46|17.63|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.46||||59.46|41.03|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.46||||59.46|17.63|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|Self-pay|Self-pay|59.46||||59.46|20.81|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|59.46||||59.46|17.63|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.46||||59.46|17.63|44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.46||||59.46||44.16|17.63
4087536|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|SUCCINYLCHOLINE CHLORIDE 20 MG/ML INJECTION WRAP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.46||||59.46||44.16|17.63
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AARP [1000]|AARP [100000]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AETNA [1015]|AETNA [101529]|6.65||||6.65|2.93|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.65||||6.65|1.97|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS [1155]|BCBS UTHCT [115568]|6.65||||6.65|3.13|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.65||||6.65|3.33|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.65||||6.65|3.33|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.65||||6.65|4.19|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.65||||6.65|1.97|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|CIGNA [1260]|CIGNA GWH [126023]|6.65||||6.65|3.66|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|6.65||||6.65|4.59|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.65||||6.65|3.33|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.65||||6.65|2.93|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.65||||6.65|1.97|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.65||||6.65|2.93|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.65||||6.65|1.97|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.65||||6.65|1.97|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|6.65||||6.65|4.59|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.65||||6.65|1.97|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|Self-pay|Self-pay|6.65||||6.65|2.33|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.65||||6.65|1.97|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.65||||6.65|1.97|4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.65||||6.65||4.59|1.97
408854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN-BACITRACN ZN-POLYMYXN 3.5 MG-400 UNIT-5,000 UNIT WRAP|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.65||||6.65||4.59|1.97
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|AARP [1000]|AARP [100000]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|AETNA [1015]|AETNA [101529]|34.38||||34.38|15.16|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34.38||||34.38|10.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|BCBS [1155]|BCBS UTHCT [115568]|34.38||||34.38|16.16|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34.38||||34.38|17.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34.38||||34.38|17.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34.38||||34.38|21.66|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34.38||||34.38|10.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|CIGNA [1260]|CIGNA GWH [126023]|34.38||||34.38|18.91|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|GROUP PENSION ADMIN [1450]|GPA [145000]|34.38||||34.38|23.72|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34.38||||34.38|17.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34.38||||34.38|15.16|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34.38||||34.38|10.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34.38||||34.38|15.16|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34.38||||34.38|10.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|34.38||||34.38|10.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|PHCS [1780]|PHCS MULTIPLAN [178000]|34.38||||34.38|23.72|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34.38||||34.38|10.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|Self-pay|Self-pay|34.38||||34.38|12.03|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34.38||||34.38|10.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34.38||||34.38|10.19|23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34.38||||34.38||23.72|10.19
4089922|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WHITE PETROLATUM TOPICAL OINTMENT WRAP|396 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34.38||||34.38||23.72|10.19
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|0.28||||0.28|0.12|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.28||||0.28|0.08|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|0.28||||0.28|0.13|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.28||||0.28|0.14|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.28||||0.28|0.14|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.28||||0.28|0.18|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.28||||0.28|0.08|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|0.28||||0.28|0.15|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|0.28||||0.28|0.19|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.28||||0.28|0.14|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.28||||0.28|0.12|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.28||||0.28|0.08|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.28||||0.28|0.12|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.28||||0.28|0.08|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.28||||0.28|0.08|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|0.28||||0.28|0.19|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.28||||0.28|0.08|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|0.28||||0.28|0.1|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.28||||0.28|0.08|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.28||||0.28|0.08|0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.28||||0.28||0.19|0.08
41003|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (ADULT) RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.28||||0.28||0.19|0.08
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AARP [1000]|AARP [100000]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AETNA [1015]|AETNA [101529]|1482||||1482|653.56|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1482||||1482|439.41|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BCBS UTHCT [115568]|1482||||1482|696.54|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1482||||1482|233.81|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1482||||1482|741|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1482||||1482|933.66|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1482||||1482|439.41|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|CIGNA [1260]|CIGNA GWH [126023]|1482||||1482|75|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1482||||1482|1022.58|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1482||||1482|330.56|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1482||||1482|653.56|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1482||||1482|439.41|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1482||||1482|653.56|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1482||||1482|439.41|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1482||||1482|439.41|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1482||||1482|1022.58|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1482||||1482|439.41|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|Self-pay|Self-pay|1482||||1482|518.7|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1482||||1482|439.41|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1482||||1482|439.41|1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1482||||1482||1022.58|75
41092950|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1482||||1482||1022.58|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AARP [1000]|AARP [100000]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AETNA [1015]|AETNA [101529]|2168||||2168|956.09|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2168||||2168|642.81|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS [1155]|BCBS UTHCT [115568]|2168||||2168|1018.96|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2168||||2168|562.05|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2168||||2168|1084|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2168||||2168|1365.84|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2168||||2168|642.81|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|CIGNA [1260]|CIGNA GWH [126023]|2168||||2168|75|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2168||||2168|1495.92|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2168||||2168|606.58|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2168||||2168|956.09|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2168||||2168|642.81|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2168||||2168|956.09|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2168||||2168|642.81|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2168||||2168|642.81|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2168||||2168|1495.92|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2168||||2168|642.81|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|Self-pay|Self-pay|2168||||2168|758.8|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2168||||2168|642.81|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2168||||2168|642.81|1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2168||||2168||1495.92|75
41094002|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR FIRST DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2168||||2168||1495.92|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AARP [1000]|AARP [100000]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AETNA [1015]|AETNA [101529]|1664||||1664|733.82|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1664||||1664|493.38|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS [1155]|BCBS UTHCT [115568]|1664||||1664|782.08|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1664||||1664|562.05|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1664||||1664|832|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1664||||1664|1048.32|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1664||||1664|493.38|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|CIGNA [1260]|CIGNA GWH [126023]|1664||||1664|75|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1664||||1664|1148.16|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1664||||1664|606.58|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1664||||1664|733.82|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1664||||1664|493.38|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1664||||1664|733.82|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1664||||1664|493.38|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1664||||1664|493.38|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1664||||1664|1148.16|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1664||||1664|493.38|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|Self-pay|Self-pay|1664||||1664|582.4|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1664||||1664|493.38|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1664||||1664|493.38|1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1664||||1664||1148.16|75
41094003|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC VENTILATOR SUBSEQUENT DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1664||||1664||1148.16|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AARP [1000]|AARP [100000]|561.57||||561.57|200|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|561.57||||561.57|172.08|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AETNA [1015]|AETNA [101529]|561.57||||561.57|247.65|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|561.57||||561.57|166.51|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|561.57||||561.57|170.38|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|561.57||||561.57|170.38|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BCBS UTHCT [115568]|561.57||||561.57|263.94|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|561.57||||561.57|227.38|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|561.57||||561.57|280.79|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|561.57||||561.57|353.79|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|561.57||||561.57|166.51|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|561.57||||561.57|170.38|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|CIGNA [1260]|CIGNA GWH [126023]|561.57||||561.57|75|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|561.57||||561.57|387.48|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|561.57||||561.57|234.85|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|561.57||||561.57|182.47|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|561.57||||561.57|247.65|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|561.57||||561.57|166.51|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|561.57||||561.57|170.38|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|561.57||||561.57|247.65|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|561.57||||561.57|166.51|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|561.57||||561.57|166.51|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|561.57||||561.57|387.48|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|561.57||||561.57|166.51|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|Self-pay|Self-pay|561.57||||561.57|196.55|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|561.57||||561.57|166.51|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|561.57||||561.57|166.51|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|561.57||||561.57|200|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|561.57||||561.57|170.38|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|561.57||||561.57|170.38|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|561.57||||561.57|200|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|561.57||||561.57|170.38|387.48|75
41094640|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|561.57||||561.57|340.75|387.48|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AARP [1000]|AARP [100000]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AETNA [1015]|AETNA [101529]|396||||396|174.64|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|396||||396|117.41|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BCBS UTHCT [115568]|396||||396|186.12|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|396||||396|227.38|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|396||||396|198|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|396||||396|249.48|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|396||||396|117.41|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|CIGNA [1260]|CIGNA GWH [126023]|396||||396|75|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|396||||396|273.24|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|396||||396|234.85|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|396||||396|174.64|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|396||||396|117.41|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|396||||396|174.64|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|396||||396|117.41|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|396||||396|117.41|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|396||||396|273.24|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|396||||396|117.41|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|Self-pay|Self-pay|396||||396|138.6|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|396||||396|117.41|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|396||||396|117.41|273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|396||||396||273.24|75
41094642|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL INHALATION PENTAMIDINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|396||||396||273.24|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AARP [1000]|AARP [100000]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AETNA [1015]|AETNA [101529]|637||||637|280.92|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|637||||637|188.87|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BCBS UTHCT [115568]|637||||637|299.39|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|637||||637|227.38|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|637||||637|318.5|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|637||||637|401.31|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|637||||637|188.87|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|CIGNA [1260]|CIGNA GWH [126023]|637||||637|75|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|637||||637|439.53|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|637||||637|234.85|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|637||||637|280.92|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|637||||637|188.87|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|637||||637|280.92|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|637||||637|188.87|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|637||||637|188.87|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|637||||637|439.53|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|637||||637|188.87|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|Self-pay|Self-pay|637||||637|222.95|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|637||||637|188.87|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|637||||637|188.87|439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|637||||637||439.53|75
41094660|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CPAP PER DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|637||||637||439.53|75
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AARP [1000]|AARP [100000]|252||||252|200|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|252||||252|172.08|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AETNA [1015]|AETNA [101529]|252||||252|111.13|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|252||||252|74.72|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|252||||252|170.38|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|252||||252|170.38|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BCBS UTHCT [115568]|252||||252|118.44|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|252||||252|227.38|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|252||||252|126|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|252||||252|158.76|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|252||||252|74.72|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|252||||252|170.38|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|CIGNA [1260]|CIGNA GWH [126023]|252||||252|75|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|252||||252|173.88|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|252||||252|234.85|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|252||||252|182.47|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|252||||252|111.13|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|252||||252|74.72|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|252||||252|170.38|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|252||||252|111.13|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|252||||252|74.72|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|252||||252|74.72|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|252||||252|173.88|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|252||||252|74.72|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|Self-pay|Self-pay|252||||252|88.2|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|252||||252|74.72|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|252||||252|74.72|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|252||||252|200|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|252||||252|170.38|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|252||||252|170.38|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|252||||252|200|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|252||||252|170.38|340.75|74.72
41094664|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC AEROSOL/NEBULIZER/INHALER/IPPB DEMO OR EVAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|252||||252|340.75|340.75|74.72
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AARP [1000]|AARP [100000]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AETNA [1015]|AETNA [101529]|220||||220|97.02|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|220||||220|65.23|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BCBS UTHCT [115568]|220||||220|103.4|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|220||||220|128.15|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|220||||220|110|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|220||||220|138.6|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|220||||220|65.23|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|CIGNA [1260]|CIGNA GWH [126023]|220||||220|75|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|220||||220|151.8|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|220||||220|139.94|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|220||||220|97.02|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|220||||220|65.23|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|220||||220|97.02|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|220||||220|65.23|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|220||||220|65.23|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|220||||220|151.8|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|220||||220|65.23|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|Self-pay|Self-pay|220||||220|77|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|220||||220|65.23|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|220||||220|65.23|151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|220||||220||151.8|65.23
41094667|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY DEMO/EVAL INITIAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AARP [1000]|AARP [100000]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AETNA [1015]|AETNA [101529]|220||||220|97.02|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|220||||220|65.23|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS [1155]|BCBS UTHCT [115568]|220||||220|103.4|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|220||||220|128.15|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|220||||220|110|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|220||||220|138.6|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|220||||220|65.23|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|CIGNA [1260]|CIGNA GWH [126023]|220||||220|75|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|220||||220|151.8|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|220||||220|139.94|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|220||||220|97.02|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|220||||220|65.23|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|220||||220|97.02|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|220||||220|65.23|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|220||||220|65.23|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|220||||220|151.8|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|220||||220|65.23|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|Self-pay|Self-pay|220||||220|77|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|220||||220|65.23|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|220||||220|65.23|151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|220||||220||151.8|65.23
41094668|EAP|0410 - RESPIRATORY SERVICES-GENERAL|HC CHEST PHYSIOTHERAPY SUBSEQUENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|220||||220||151.8|65.23
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|AARP [1000]|AARP [100000]|105||||105|65|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105||||105|24.02|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|AETNA [1015]|AETNA [101529]|105||||105|105|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105||||105|31.13|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105||||105|23.79|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105||||105|23.79|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|105||||105|49.35|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105||||105|15.32|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105||||105|52.5|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105||||105|66.15|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105||||105|31.13|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105||||105|23.79|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|105||||105|57.75|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|105||||105|72.45|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105||||105|32.79|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105||||105|25.47|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105||||105|105|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105||||105|31.13|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105||||105|23.79|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105||||105|105|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105||||105|31.13|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|105||||105|31.13|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|105||||105|72.45|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105||||105|31.13|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|Self-pay|Self-pay|105||||105|36.75|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105||||105|31.13|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105||||105|31.13|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105||||105|65|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105||||105|23.79|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105||||105|23.79|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105||||105|65|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105||||105|23.79|105|15.32
41099406|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING 3-10 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105||||105|47.57|105|15.32
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|AARP [1000]|AARP [100000]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|AETNA [1015]|AETNA [101529]|105||||105|105|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105||||105|31.13|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|105||||105|49.35|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105||||105|31.96|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105||||105|52.5|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105||||105|66.15|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105||||105|31.13|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|105||||105|57.75|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|105||||105|72.45|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105||||105|32.79|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105||||105|105|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105||||105|31.13|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105||||105|105|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105||||105|31.13|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|105||||105|31.13|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|105||||105|72.45|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105||||105|31.13|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|Self-pay|Self-pay|105||||105|36.75|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105||||105|31.13|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105||||105|31.13|105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105||||105||105|31.13
41099407|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC BEHAV CHNG SMOKING > 10 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105||||105||105|31.13
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|180.3||||180.3|81.14|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|180.3||||180.3|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|180.3||||180.3|53.46|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|180.3||||180.3|84.74|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|180.3||||180.3|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|180.3||||180.3|90.15|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|180.3||||180.3|113.59|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|180.3||||180.3|53.46|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|180.3||||180.3|99.17|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|180.3||||180.3|124.41|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|180.3||||180.3|2.26|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|180.3||||180.3|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|180.3||||180.3|53.46|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|180.3||||180.3|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|180.3||||180.3|53.46|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|180.3||||180.3|53.46|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|180.3||||180.3|124.41|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|180.3||||180.3|53.46|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|180.3||||180.3|63.1|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|180.3||||180.3|53.46|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|180.3||||180.3|53.46|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|180.3||||180.3|81.14|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|180.3||||180.3|81.14|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|180.3||||180.3||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|AARP [1000]|AARP [100000]|263.85||||263.85|118.73|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|263.85||||263.85|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|263.85||||263.85|78.23|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|263.85||||263.85|124.01|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|263.85||||263.85|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|263.85||||263.85|131.93|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|263.85||||263.85|166.23|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|263.85||||263.85|78.23|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|263.85||||263.85|145.12|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|263.85||||263.85|182.06|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|263.85||||263.85|2.26|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|263.85||||263.85|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|263.85||||263.85|78.23|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|263.85||||263.85|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|263.85||||263.85|78.23|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|263.85||||263.85|78.23|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|263.85||||263.85|182.06|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|263.85||||263.85|78.23|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|Self-pay|Self-pay|263.85||||263.85|92.35|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|263.85||||263.85|78.23|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|263.85||||263.85|78.23|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|263.85||||263.85|118.73|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|263.85||||263.85|118.73|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|263.85||||263.85||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|325.81||||325.81|146.61|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|325.81||||325.81||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|325.81||||325.81|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|325.81||||325.81|96.6|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|325.81||||325.81||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|325.81||||325.81||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|325.81||||325.81|153.13|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|325.81||||325.81|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|325.81||||325.81|162.91|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|325.81||||325.81|205.26|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|325.81||||325.81|96.6|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|325.81||||325.81||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|325.81||||325.81|179.2|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|325.81||||325.81|224.81|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|325.81||||325.81|2.26|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|325.81||||325.81||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|325.81||||325.81|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|325.81||||325.81|96.6|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|325.81||||325.81||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|325.81||||325.81|0|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|325.81||||325.81|96.6|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|325.81||||325.81|96.6|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|325.81||||325.81|224.81|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|325.81||||325.81|96.6|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|325.81||||325.81|114.03|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|325.81||||325.81|96.6|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|325.81||||325.81|96.6|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|325.81||||325.81|146.61|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|325.81||||325.81||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|325.81||||325.81||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|325.81||||325.81|146.61|224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|325.81||||325.81||224.81|2.26
41137|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|325.81||||325.81||224.81|2.26
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|AARP [1000]|AARP [100000]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|AETNA [1015]|AETNA [101529]|163.16||||163.16|71.95|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163.16||||163.16|48.38|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|BCBS [1155]|BCBS UTHCT [115568]|163.16||||163.16|76.69|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163.16||||163.16|81.58|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163.16||||163.16|81.58|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163.16||||163.16|102.79|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163.16||||163.16|48.38|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|CIGNA [1260]|CIGNA GWH [126023]|163.16||||163.16|89.74|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|163.16||||163.16|112.58|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|163.16||||163.16|81.58|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163.16||||163.16|71.95|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163.16||||163.16|48.38|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163.16||||163.16|71.95|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163.16||||163.16|48.38|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|163.16||||163.16|48.38|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|163.16||||163.16|112.58|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163.16||||163.16|48.38|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|Self-pay|Self-pay|163.16||||163.16|57.11|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|163.16||||163.16|48.38|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163.16||||163.16|48.38|112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163.16||||163.16||112.58|48.38
41141|ERX|0250 - PHARMACY-GENERAL|MEDROXYPROGESTERONE 104 MG/0.65 ML SUBCUTANEOUS SYRINGE|0.65 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163.16||||163.16||112.58|48.38
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|AARP [1000]|AARP [100000]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|AETNA [1015]|AETNA [101529]|1326.35||||1326.35|584.92|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1326.35||||1326.35|393.26|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|BCBS [1155]|BCBS UTHCT [115568]|1326.35||||1326.35|623.38|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1326.35||||1326.35|663.18|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1326.35||||1326.35|663.18|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1326.35||||1326.35|835.6|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1326.35||||1326.35|393.26|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|CIGNA [1260]|CIGNA GWH [126023]|1326.35||||1326.35|729.49|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1326.35||||1326.35|915.18|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1326.35||||1326.35|663.18|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1326.35||||1326.35|584.92|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1326.35||||1326.35|393.26|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1326.35||||1326.35|584.92|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1326.35||||1326.35|393.26|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|1326.35||||1326.35|393.26|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1326.35||||1326.35|915.18|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1326.35||||1326.35|393.26|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|Self-pay|Self-pay|1326.35||||1326.35|464.22|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1326.35||||1326.35|393.26|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1326.35||||1326.35|393.26|915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1326.35||||1326.35||915.18|393.26
41142|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|IPRATROPIUM BROMIDE 17 MCG/ACTUATION HFA AEROSOL INHALER|12.9 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1326.35||||1326.35||915.18|393.26
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|128.07||||128.07|56.48|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.07||||128.07|37.97|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|128.07||||128.07|60.19|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128.07||||128.07|0|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128.07||||128.07|64.04|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128.07||||128.07|80.68|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128.07||||128.07|37.97|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|128.07||||128.07|70.44|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|128.07||||128.07|88.37|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|128.07||||128.07|42.58|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.07||||128.07|56.48|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128.07||||128.07|37.97|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.07||||128.07|56.48|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.07||||128.07|37.97|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|128.07||||128.07|37.97|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|128.07||||128.07|88.37|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128.07||||128.07|37.97|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|128.07||||128.07|44.82|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|128.07||||128.07|37.97|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128.07||||128.07|37.97|88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128.07||||128.07||88.37|37.97
41293|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUSSIS(ACEL),TETANUS 2.5 LF UNIT-8 MCG-5 LF/0.5ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128.07||||128.07||88.37|37.97
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AARP [1000]|AARP [100000]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AETNA [1015]|AETNA [101529]|50.36||||50.36|22.21|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.36||||50.36|14.93|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BCBS UTHCT [115568]|50.36||||50.36|23.67|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.36||||50.36|25.18|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.36||||50.36|25.18|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.36||||50.36|31.73|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.36||||50.36|14.93|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|CIGNA [1260]|CIGNA GWH [126023]|50.36||||50.36|27.7|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|GROUP PENSION ADMIN [1450]|GPA [145000]|50.36||||50.36|34.75|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50.36||||50.36|25.18|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.36||||50.36|22.21|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.36||||50.36|14.93|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.36||||50.36|22.21|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.36||||50.36|14.93|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|PENDING SSI [1616]|PENDING SSI RCA [161601]|50.36||||50.36|14.93|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|PHCS [1780]|PHCS MULTIPLAN [178000]|50.36||||50.36|34.75|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.36||||50.36|14.93|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|Self-pay|Self-pay|50.36||||50.36|17.63|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50.36||||50.36|14.93|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.36||||50.36|14.93|34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.36||||50.36||34.75|14.93
41382|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FENTANYL 12 MCG/HR TRANSDERMAL PATCH|1 patch|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.36||||50.36||34.75|14.93
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AARP [1000]|AARP [100000]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AETNA [1015]|AETNA [101529]|2.52||||2.52|1.11|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.52||||2.52|0.75|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BCBS UTHCT [115568]|2.52||||2.52|1.18|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.52||||2.52|1.26|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.52||||2.52|1.26|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.52||||2.52|1.59|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.52||||2.52|0.75|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|CIGNA [1260]|CIGNA GWH [126023]|2.52||||2.52|1.39|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.52||||2.52|1.74|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.52||||2.52|1.26|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.52||||2.52|1.11|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.52||||2.52|0.75|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.52||||2.52|1.11|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.52||||2.52|0.75|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.52||||2.52|0.75|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.52||||2.52|1.74|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.52||||2.52|0.75|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|Self-pay|Self-pay|2.52||||2.52|0.88|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.52||||2.52|0.75|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.52||||2.52|0.75|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.52||||2.52||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AARP [1000]|AARP [100000]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AETNA [1015]|AETNA [101529]|4.53||||4.53|2|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.53||||4.53|1.34|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BCBS UTHCT [115568]|4.53||||4.53|2.13|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.53||||4.53|2.27|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.53||||4.53|2.27|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.53||||4.53|2.85|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.53||||4.53|1.34|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|CIGNA [1260]|CIGNA GWH [126023]|4.53||||4.53|2.49|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.53||||4.53|3.13|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.53||||4.53|2.27|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.53||||4.53|2|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.53||||4.53|1.34|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.53||||4.53|2|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.53||||4.53|1.34|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.53||||4.53|1.34|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.53||||4.53|3.13|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.53||||4.53|1.34|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|Self-pay|Self-pay|4.53||||4.53|1.59|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.53||||4.53|1.34|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.53||||4.53|1.34|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.53||||4.53||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|AARP [1000]|AARP [100000]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|AETNA [1015]|AETNA [101529]|7.91||||7.91|3.49|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.91||||7.91|2.35|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|BCBS [1155]|BCBS UTHCT [115568]|7.91||||7.91|3.72|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.91||||7.91|3.96|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.91||||7.91|3.96|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.91||||7.91|4.98|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.91||||7.91|2.35|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|CIGNA [1260]|CIGNA GWH [126023]|7.91||||7.91|4.35|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.91||||7.91|5.46|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.91||||7.91|3.96|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.91||||7.91|3.49|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.91||||7.91|2.35|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.91||||7.91|3.49|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.91||||7.91|2.35|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.91||||7.91|2.35|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.91||||7.91|5.46|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.91||||7.91|2.35|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|Self-pay|Self-pay|7.91||||7.91|2.77|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.91||||7.91|2.35|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.91||||7.91|2.35|5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.91||||7.91||5.46|0.75
41463|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % (PF) INJECTION SOLUTION *VIAL* REPACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.91||||7.91||5.46|0.75
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|AARP [1000]|AARP [100000]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|9.74||||9.74|4.3|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.74||||9.74|2.89|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|9.74||||9.74|4.58|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.74||||9.74|4.87|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.74||||9.74|4.87|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.74||||9.74|6.14|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.74||||9.74|2.89|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|9.74||||9.74|5.36|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.74||||9.74|6.72|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.74||||9.74|4.87|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.74||||9.74|4.3|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.74||||9.74|2.89|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.74||||9.74|4.3|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.74||||9.74|2.89|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.74||||9.74|2.89|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.74||||9.74|6.72|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.74||||9.74|2.89|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|Self-pay|Self-pay|9.74||||9.74|3.41|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.74||||9.74|2.89|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.74||||9.74|2.89|6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.74||||9.74||6.72|2.89
41623|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOCARNITINE (WITH SUGAR) 100 MG/ML ORAL SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.74||||9.74||6.72|2.89
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|AARP [1000]|AARP [100000]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|AETNA [1015]|AETNA [101529]|142.26||||142.26|62.74|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|142.26||||142.26|42.18|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|142.26||||142.26|66.86|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|142.26||||142.26|0|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|142.26||||142.26|71.13|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|142.26||||142.26|89.62|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|142.26||||142.26|42.18|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|142.26||||142.26|78.24|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|142.26||||142.26|98.16|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|142.26||||142.26|42.58|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|142.26||||142.26|62.74|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|142.26||||142.26|42.18|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|142.26||||142.26|62.74|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|142.26||||142.26|42.18|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|142.26||||142.26|42.18|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|142.26||||142.26|98.16|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|142.26||||142.26|42.18|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|Self-pay|Self-pay|142.26||||142.26|49.79|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|142.26||||142.26|42.18|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|142.26||||142.26|42.18|98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|142.26||||142.26||98.16|42.18
41628|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIPHTH,PERTUS(ACEL)TETANUS(PF)2LF-(2.5-5-3-5MCG)-5 LF/0.5 ML IM SUSP|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|142.26||||142.26||98.16|42.18
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|AARP [1000]|AARP [100000]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA [1015]|AETNA [101529]|388.12||||388.12|174|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|388.12||||388.12|115.08|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BCBS UTHCT [115568]|388.12||||388.12|182.42|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|388.12||||388.12|0|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|388.12||||388.12|194.06|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|388.12||||388.12|244.52|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|388.12||||388.12|115.08|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA GWH [126023]|388.12||||388.12|213.47|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|388.12||||388.12|267.8|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|388.12||||388.12|1.49|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|388.12||||388.12|174|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|388.12||||388.12|115.08|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|388.12||||388.12|174|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|388.12||||388.12|115.08|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|388.12||||388.12|115.08|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|388.12||||388.12|267.8|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|388.12||||388.12|115.08|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|Self-pay|Self-pay|388.12||||388.12|135.84|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|388.12||||388.12|115.08|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|388.12||||388.12|115.08|267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|388.12||||388.12||267.8|1.49
41652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TIGECYCLINE 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|388.12||||388.12||267.8|1.49
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|242.2||||242.2|106.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|242.2||||242.2|71.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|242.2||||242.2|113.83|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|242.2||||242.2|121.1|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|242.2||||242.2|121.1|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|242.2||||242.2|152.59|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|242.2||||242.2|71.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|242.2||||242.2|133.21|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|242.2||||242.2|167.12|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|242.2||||242.2|121.1|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|242.2||||242.2|106.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|242.2||||242.2|71.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|242.2||||242.2|106.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|242.2||||242.2|71.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|242.2||||242.2|71.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|242.2||||242.2|167.12|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|242.2||||242.2|71.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|242.2||||242.2|84.77|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|242.2||||242.2|71.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|242.2||||242.2|71.81|167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|242.2||||242.2||167.12|71.81
41787|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 1 % (10 MG/ML) INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|242.2||||242.2|106.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|242.2||||242.2|71.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|242.2||||242.2|113.83|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|242.2||||242.2|121.1|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|242.2||||242.2|121.1|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|242.2||||242.2|152.59|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|242.2||||242.2|71.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|242.2||||242.2|133.21|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|242.2||||242.2|167.12|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|242.2||||242.2|121.1|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|242.2||||242.2|106.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|242.2||||242.2|71.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|242.2||||242.2|106.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|242.2||||242.2|71.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|242.2||||242.2|71.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|242.2||||242.2|167.12|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|242.2||||242.2|71.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|242.2||||242.2|84.77|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|242.2||||242.2|71.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|242.2||||242.2|71.81|167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|242.2||||242.2||167.12|71.81
41793|ERX|0250 - PHARMACY-GENERAL|SODIUM TETRADECYL SULFATE 3 % (30 MG/ML) INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|242.2||||242.2||167.12|71.81
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AARP [1000]|AARP [100000]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AETNA [1015]|AETNA [101529]|1488||||1488|656.21|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1488||||1488|441.19|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS [1155]|BCBS UTHCT [115568]|1488||||1488|699.36|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1488||||1488|744|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1488||||1488|744|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1488||||1488|937.44|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1488||||1488|441.19|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|CIGNA [1260]|CIGNA GWH [126023]|1488||||1488|818.4|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1488||||1488|1026.72|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1488||||1488|744|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1488||||1488|656.21|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1488||||1488|441.19|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1488||||1488|656.21|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1488||||1488|441.19|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|1488||||1488|441.19|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1488||||1488|1026.72|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1488||||1488|441.19|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|Self-pay|Self-pay|1488||||1488|520.8|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1488||||1488|441.19|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1488||||1488|441.19|1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1488||||1488||1026.72|441.19
41831|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE 5 % TOPICAL OINTMENT|36 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1488||||1488||1026.72|441.19
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.69||||3.69|1.63|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.69||||3.69|1.09|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.69||||3.69|1.73|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.69||||3.69|1.85|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.69||||3.69|1.85|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.69||||3.69|2.32|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.69||||3.69|1.09|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.69||||3.69|2.03|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.69||||3.69|2.55|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.69||||3.69|1.85|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.69||||3.69|1.63|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.69||||3.69|1.09|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.69||||3.69|1.63|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.69||||3.69|1.09|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.69||||3.69|1.09|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.69||||3.69|2.55|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.69||||3.69|1.09|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|Self-pay|Self-pay|3.69||||3.69|1.29|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.69||||3.69|1.09|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.69||||3.69|1.09|2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.69||||3.69||2.55|1.09
41832|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.69||||3.69||2.55|1.09
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AARP [1000]|AARP [100000]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AETNA [1015]|AETNA [101529]|214||||214|94.37|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|63.45|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS [1155]|BCBS UTHCT [115568]|214||||214|100.58|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|107|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|107|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|134.82|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|63.45|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|CIGNA [1260]|CIGNA GWH [126023]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214||||214|107|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|94.37|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|63.45|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|94.37|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|63.45|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214||||214|63.45|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|63.45|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|Self-pay|Self-pay|214||||214|74.9|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214||||214|63.45|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|63.45|147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214||147.66|63.45
42029200|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING THORAX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214||147.66|63.45
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AARP [1000]|AARP [100000]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AETNA [1015]|AETNA [101529]|296||||296|130.54|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|296||||296|87.76|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS [1155]|BCBS UTHCT [115568]|296||||296|139.12|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|296||||296|148|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|296||||296|148|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|296||||296|186.48|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|296||||296|87.76|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|CIGNA [1260]|CIGNA GWH [126023]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|296||||296|204.24|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|296||||296|148|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|296||||296|130.54|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|296||||296|87.76|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|296||||296|130.54|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|296||||296|87.76|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|296||||296|87.76|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|296||||296|204.24|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|296||||296|87.76|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|Self-pay|Self-pay|296||||296|103.6|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|296||||296|87.76|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|296||||296|87.76|204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|296||||296||204.24|87.76
42029240|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|296||||296||204.24|87.76
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AARP [1000]|AARP [100000]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AETNA [1015]|AETNA [101529]|214||||214|94.37|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|63.45|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS [1155]|BCBS UTHCT [115568]|214||||214|100.58|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|107|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|107|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|134.82|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|63.45|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|CIGNA [1260]|CIGNA GWH [126023]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214||||214|107|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|94.37|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|63.45|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|94.37|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|63.45|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214||||214|63.45|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|63.45|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|Self-pay|Self-pay|214||||214|74.9|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214||||214|63.45|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|63.45|147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214||147.66|63.45
42029260|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AARP [1000]|AARP [100000]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AETNA [1015]|AETNA [101529]|214||||214|94.37|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|63.45|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS [1155]|BCBS UTHCT [115568]|214||||214|100.58|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|107|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|107|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|134.82|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|63.45|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|CIGNA [1260]|CIGNA GWH [126023]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214||||214|107|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|94.37|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|63.45|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|94.37|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|63.45|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214||||214|63.45|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|63.45|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|Self-pay|Self-pay|214||||214|74.9|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214||||214|63.45|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|63.45|147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214||147.66|63.45
42029520|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING HIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214||147.66|63.45
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|AARP [1000]|AARP [100000]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|AETNA [1015]|AETNA [101529]|235||||235|103.64|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|235||||235|69.68|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|BCBS [1155]|BCBS UTHCT [115568]|235||||235|110.45|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|235||||235|117.5|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|235||||235|117.5|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|235||||235|148.05|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|235||||235|69.68|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|CIGNA [1260]|CIGNA GWH [126023]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|235||||235|162.15|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|235||||235|117.5|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|235||||235|103.64|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|235||||235|69.68|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|235||||235|103.64|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|235||||235|69.68|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|235||||235|69.68|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|235||||235|162.15|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|235||||235|69.68|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|Self-pay|Self-pay|235||||235|82.25|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|235||||235|69.68|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|235||||235|69.68|162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|235||||235||162.15|69.68
42029530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING KNEE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|235||||235||162.15|69.68
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|AARP [1000]|AARP [100000]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|AETNA [1015]|AETNA [101529]|386||||386|170.23|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386||||386|114.45|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS [1155]|BCBS UTHCT [115568]|386||||386|181.42|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386||||386|193|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386||||386|193|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386||||386|243.18|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386||||386|114.45|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|CIGNA [1260]|CIGNA GWH [126023]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386||||386|266.34|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|386||||386|193|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386||||386|170.23|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386||||386|114.45|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386||||386|170.23|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386||||386|114.45|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|386||||386|114.45|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386||||386|266.34|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386||||386|114.45|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|Self-pay|Self-pay|386||||386|135.1|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|386||||386|114.45|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386||||386|114.45|266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386||||386||266.34|114.45
42029540|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING ANKLE/FOOT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386||||386||266.34|114.45
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|AARP [1000]|AARP [100000]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|AETNA [1015]|AETNA [101529]|244||||244|107.6|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244||||244|72.35|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|BCBS [1155]|BCBS UTHCT [115568]|244||||244|114.68|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244||||244|122|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244||||244|122|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244||||244|153.72|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244||||244|72.35|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|CIGNA [1260]|CIGNA GWH [126023]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|244||||244|168.36|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|244||||244|122|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244||||244|107.6|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244||||244|72.35|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244||||244|107.6|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244||||244|72.35|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|244||||244|72.35|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|244||||244|168.36|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244||||244|72.35|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|Self-pay|Self-pay|244||||244|85.4|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|244||||244|72.35|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244||||244|72.35|168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244||||244||168.36|72.35
42029550|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC STRAPPING TOES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244||||244||168.36|72.35
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AARP [1000]|AARP [100000]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AETNA [1015]|AETNA [101529]|694||||694|306.05|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|694||||694|205.77|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS [1155]|BCBS UTHCT [115568]|694||||694|326.18|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|694||||694|347|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|694||||694|347|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|694||||694|437.22|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|694||||694|205.77|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|CIGNA [1260]|CIGNA GWH [126023]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|694||||694|478.86|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|694||||694|347|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|694||||694|306.05|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|694||||694|205.77|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|694||||694|306.05|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|694||||694|205.77|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|694||||694|205.77|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|694||||694|478.86|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|694||||694|205.77|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|Self-pay|Self-pay|694||||694|242.9|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|694||||694|205.77|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|694||||694|41.3|478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|694||||694||478.86|41.3
42029581|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC APP MULTILY COMPRS LWR LEG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|694||||694||478.86|41.3
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AARP [1000]|AARP [100000]|113||||113|65|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|113||||113|36.68|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AETNA [1015]|AETNA [101529]|113||||113|49.83|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|113||||113|33.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|113||||113|36.32|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|113||||113|36.32|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS [1155]|BCBS UTHCT [115568]|113||||113|53.11|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|113||||113|46.85|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|113||||113|56.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|113||||113|71.19|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|113||||113|33.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|113||||113|36.32|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|CIGNA [1260]|CIGNA GWH [126023]|113||||113|75|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|113||||113|77.97|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|113||||113|56.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|113||||113|36.32|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|113||||113|49.83|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|113||||113|33.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|113||||113|36.32|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|113||||113|49.83|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|113||||113|33.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|113||||113|33.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|113||||113|77.97|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|113||||113|33.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|Self-pay|Self-pay|113||||113|39.55|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|113||||113|33.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|113||||113|33.5|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|113||||113|65|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|113||||113|36.32|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|113||||113|36.32|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|113||||113|65|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|113||||113|36.32|77.97|33.5
42095992|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC CANALITH REPOSITIONING PER DAY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|113||||113|72.64|77.97|33.5
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AARP [1000]|AARP [100000]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AETNA [1015]|AETNA [101529]|31||||31|9.02|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|9.19|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|7.88|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|9.19|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|CIGNA [1260]|CIGNA GWH [126023]|31||||31|31|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|15.5|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|9.02|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|9.19|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|9.02|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|9.19|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|9.19|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|9.19|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|Self-pay|Self-pay|31||||31|10.85|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|9.19|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|9.19|31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31||31|7.88
42097010|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC HOT/COLD PACK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31||31|7.88
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AARP [1000]|AARP [100000]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AETNA [1015]|AETNA [101529]|104||||104|21.82|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104||||104|30.84|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BCBS UTHCT [115568]|104||||104|48.88|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104||||104|18.39|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104||||104|52|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104||||104|65.52|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104||||104|30.84|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|CIGNA [1260]|CIGNA GWH [126023]|104||||104|75|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|104||||104|71.76|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|104||||104|52|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104||||104|21.82|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104||||104|30.84|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104||||104|21.82|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104||||104|30.84|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|104||||104|30.84|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|104||||104|71.76|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104||||104|30.84|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|Self-pay|Self-pay|104||||104|36.4|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|104||||104|30.84|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104||||104|30.84|75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104||||104||75|18.39
42097012|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT TRACTION MECHANICAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104||||104||75|18.39
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AARP [1000]|AARP [100000]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA [1015]|AETNA [101529]|221||||221|25.94|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|221||||221|65.53|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BCBS UTHCT [115568]|221||||221|103.87|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|221||||221|23.64|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|221||||221|110.5|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|221||||221|139.23|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|221||||221|65.53|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA [1260]|CIGNA GWH [126023]|221||||221|75|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|221||||221|152.49|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|221||||221|110.5|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|221||||221|25.94|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|221||||221|65.53|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|221||||221|25.94|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|221||||221|65.53|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|221||||221|65.53|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|221||||221|152.49|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|221||||221|65.53|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|Self-pay|Self-pay|221||||221|77.35|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|221||||221|65.53|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|221||||221|65.53|152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|221||||221||152.49|23.64
42097022|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|221||||221||152.49|23.64
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AARP [1000]|AARP [100000]|133||||133|65|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|133||||133|14.74|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AETNA [1015]|AETNA [101529]|133||||133|21.31|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|133||||133|39.43|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|133||||133|14.59|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|133||||133|14.59|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BCBS UTHCT [115568]|133||||133|62.51|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|133||||133|19.26|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|133||||133|66.5|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|133||||133|83.79|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|133||||133|39.43|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|133||||133|14.59|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|CIGNA [1260]|CIGNA GWH [126023]|133||||133|75|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|133||||133|91.77|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|133||||133|66.5|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|133||||133|14.59|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|133||||133|21.31|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|133||||133|39.43|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|133||||133|14.59|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|133||||133|21.31|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|133||||133|39.43|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|133||||133|39.43|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|133||||133|91.77|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|133||||133|39.43|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|Self-pay|Self-pay|133||||133|46.55|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|133||||133|39.43|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|133||||133|39.43|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|133||||133|65|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|133||||133|14.59|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|133||||133|14.59|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|133||||133|65|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|133||||133|14.59|91.77|14.59
42097032|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ELECTRICAL STIM ATTENDED 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|133||||133|29.18|91.77|14.59
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AARP [1000]|AARP [100000]|81||||81|65|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81||||81|20.14|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AETNA [1015]|AETNA [101529]|81||||81|30.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81||||81|24.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81||||81|19.94|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|81||||81|19.94|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|81||||81|38.07|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81||||81|25.83|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81||||81|40.5|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81||||81|51.03|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81||||81|24.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81||||81|19.94|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|81||||81|75|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|81||||81|55.89|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|81||||81|40.5|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|81||||81|19.94|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81||||81|30.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81||||81|24.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81||||81|19.94|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81||||81|30.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|81||||81|24.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|81||||81|24.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|81||||81|55.89|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81||||81|24.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|Self-pay|Self-pay|81||||81|28.35|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|81||||81|24.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81||||81|24.02|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81||||81|65|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|81||||81|19.94|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|81||||81|19.94|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81||||81|65|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81||||81|19.94|75|19.94
42097033|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC IONTOPHORESIS 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|81||||81|39.88|75|19.94
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AARP [1000]|AARP [100000]|122||||122|65|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122||||122|14.34|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AETNA [1015]|AETNA [101529]|122||||122|20.81|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122||||122|36.17|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122||||122|14.2|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122||||122|14.2|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|122||||122|57.34|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122||||122|16.64|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122||||122|61|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122||||122|76.86|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122||||122|36.17|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122||||122|14.2|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|122||||122|75|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|122||||122|84.18|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|122||||122|61|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122||||122|14.2|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122||||122|20.81|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122||||122|36.17|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122||||122|14.2|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122||||122|20.81|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122||||122|36.17|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|122||||122|36.17|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|122||||122|84.18|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122||||122|36.17|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|Self-pay|Self-pay|122||||122|42.7|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|122||||122|36.17|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122||||122|36.17|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122||||122|65|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|122||||122|14.2|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|122||||122|14.2|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122||||122|65|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122||||122|14.2|84.18|14.2
42097035|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ULTRASOUND THERAPY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122||||122|28.4|84.18|14.2
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AARP [1000]|AARP [100000]|181||||181|65|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181||||181|29.73|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA [1015]|AETNA [101529]|181||||181|44.16|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181||||181|53.67|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181||||181|29.44|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181||||181|29.44|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|181||||181|85.07|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181||||181|38.09|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181||||181|90.5|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181||||181|114.03|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181||||181|53.67|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181||||181|29.44|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|181||||181|75|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|181||||181|124.89|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|181||||181|90.5|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181||||181|29.44|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181||||181|44.16|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181||||181|53.67|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181||||181|29.44|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181||||181|44.16|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181||||181|53.67|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|181||||181|53.67|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|181||||181|124.89|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181||||181|53.67|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|Self-pay|Self-pay|181||||181|63.35|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|181||||181|53.67|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181||||181|53.67|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181||||181|65|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|181||||181|29.44|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|181||||181|29.44|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181||||181|65|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181||||181|29.44|124.89|29.44
42097110|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181||||181|58.88|124.89|29.44
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AARP [1000]|AARP [100000]|189||||189|65|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189|34.52|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA [1015]|AETNA [101529]|189||||189|50.83|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189|56.04|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189|34.18|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189|34.18|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|43.35|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189|56.04|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189|34.18|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|75|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|94.5|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189|34.18|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|50.83|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189|56.04|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189|34.18|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|50.83|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189|56.04|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189|56.04|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189|56.04|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|Self-pay|Self-pay|189||||189|66.15|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189|56.04|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189|56.04|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189|65|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189|34.18|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189|34.18|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189|65|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189|34.18|130.41|34.18
42097112|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189|68.36|130.41|34.18
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AARP [1000]|AARP [100000]|166||||166|65|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|166||||166|29.73|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AETNA [1015]|AETNA [101529]|166||||166|43.66|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|166||||166|49.22|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|166||||166|29.44|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|166||||166|29.44|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|166||||166|78.02|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|166||||166|37.65|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|166||||166|83|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|166||||166|104.58|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|166||||166|49.22|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|166||||166|29.44|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|166||||166|75|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|166||||166|114.54|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|166||||166|83|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|166||||166|29.44|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|166||||166|43.66|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|166||||166|49.22|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|166||||166|29.44|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|166||||166|43.66|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|166||||166|49.22|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|166||||166|49.22|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|166||||166|114.54|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|166||||166|49.22|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|Self-pay|Self-pay|166||||166|58.1|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|166||||166|49.22|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|166||||166|49.22|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|166||||166|65|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|166||||166|29.44|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|166||||166|29.44|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|166||||166|65|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|166||||166|29.44|114.54|29.44
42097116|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC GAIT TRAINING 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|166||||166|58.88|114.54|29.44
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AARP [1000]|AARP [100000]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AETNA [1015]|AETNA [101529]|75||||75|42.31|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75||||75|22.24|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|75||||75|35.25|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75||||75|38.09|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75||||75|37.5|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75||||75|47.25|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75||||75|22.24|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|75||||75|75|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|75||||75|51.75|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|75||||75|37.5|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75||||75|42.31|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75||||75|22.24|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75||||75|42.31|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75||||75|22.24|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|75||||75|22.24|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|75||||75|51.75|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75||||75|22.24|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|Self-pay|Self-pay|75||||75|26.25|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|75||||75|22.24|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75||||75|22.24|75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75||||75||75|22.24
42097124|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75||||75||75|22.24
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AARP [1000]|AARP [100000]|132||||132|65|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132||||132|27.34|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA [1015]|AETNA [101529]|132||||132|40.58|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132||||132|39.14|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132||||132|27.07|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132||||132|27.07|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|132||||132|62.04|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132||||132|34.59|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132||||132|66|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132||||132|83.16|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132||||132|39.14|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132||||132|27.07|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|132||||132|75|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|132||||132|91.08|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|132||||132|66|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132||||132|27.07|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132||||132|40.58|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132||||132|39.14|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132||||132|27.07|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132||||132|40.58|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132||||132|39.14|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|132||||132|39.14|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|132||||132|91.08|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132||||132|39.14|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|Self-pay|Self-pay|132||||132|46.2|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|132||||132|39.14|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132||||132|39.14|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132||||132|65|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|132||||132|27.07|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|132||||132|27.07|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132||||132|65|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132||||132|27.07|91.08|27.07
42097140|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132||||132|54.14|91.08|27.07
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AARP [1000]|AARP [100000]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AETNA [1015]|AETNA [101529]|59||||59|26.42|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59||||59|17.49|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BCBS UTHCT [115568]|59||||59|27.73|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59||||59|22.77|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59||||59|29.5|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59||||59|37.17|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59||||59|17.49|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA [1260]|CIGNA GWH [126023]|59||||59|59|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|59||||59|40.71|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|59||||59|29.5|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59||||59|26.42|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59||||59|17.49|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59||||59|26.42|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59||||59|17.49|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|59||||59|17.49|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|59||||59|40.71|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59||||59|17.49|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|Self-pay|Self-pay|59||||59|20.65|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|59||||59|17.49|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59||||59|17.49|59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59||||59||59|17.49
42097150|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59||||59||59|17.49
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AARP [1000]|AARP [100000]|156||||156|65|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|156||||156|38.47|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA [1015]|AETNA [101529]|156||||156|56.98|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|156||||156|46.25|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|156||||156|38.09|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|156||||156|38.09|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|156||||156|73.32|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|156||||156|50.35|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|156||||156|78|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|156||||156|98.28|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|156||||156|46.25|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|156||||156|38.09|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|156||||156|75|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|156||||156|107.64|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|156||||156|78|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|156||||156|38.09|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|156||||156|56.98|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|156||||156|46.25|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|156||||156|38.09|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|156||||156|56.98|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|156||||156|46.25|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|156||||156|46.25|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|156||||156|107.64|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|156||||156|46.25|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|Self-pay|Self-pay|156||||156|54.6|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|156||||156|46.25|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|156||||156|46.25|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|156||||156|65|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|156||||156|38.09|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|156||||156|38.09|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|156||||156|65|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|156||||156|38.09|107.64|38.09
42097530|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|156||||156|76.18|107.64|38.09
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AARP [1000]|AARP [100000]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AETNA [1015]|AETNA [101529]|146||||146|49.3|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146|43.29|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|146||||146|68.62|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|42.91|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|91.98|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146|43.29|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|146||||146|75|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|146||||146|73|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|49.3|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146|43.29|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|49.3|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146||||146|43.29|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|146||||146|43.29|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146|43.29|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|Self-pay|Self-pay|146||||146|51.1|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|146||||146|43.29|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146|43.29|100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146||100.74|42.91
42097535|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PT ADL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146||||146||100.74|42.91
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AARP [1000]|AARP [100000]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AETNA [1015]|AETNA [101529]|66||||66|47.23|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|19.57|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|66||||66|31.02|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|41.16|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|41.58|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|19.57|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|66||||66|66|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66||||66|33|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|47.23|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|19.57|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|47.23|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|19.57|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|66||||66|19.57|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|19.57|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|Self-pay|Self-pay|66||||66|23.1|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66||||66|19.57|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|19.57|66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||66|19.57
42097537|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||66|19.57
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AARP [1000]|AARP [100000]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA [1015]|AETNA [101529]|89||||89|47.76|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89||||89|26.39|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|89||||89|41.83|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89||||89|41.59|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89||||89|44.5|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89||||89|56.07|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89||||89|26.39|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|89||||89|75|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|89||||89|61.41|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|89||||89|44.5|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89||||89|47.76|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89||||89|26.39|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89||||89|47.76|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|89||||89|26.39|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|89||||89|26.39|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|89||||89|61.41|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89||||89|26.39|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|Self-pay|Self-pay|89||||89|31.15|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|89||||89|26.39|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89||||89|26.39|75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89||||89||75|26.39
42097542|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|89||||89||75|26.39
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AARP [1000]|AARP [100000]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA [1015]|AETNA [101529]|193||||193|85.11|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193||||193|57.22|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|193||||193|90.71|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193||||193|46.85|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193||||193|96.5|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193||||193|121.59|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193||||193|57.22|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|193||||193|75|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|193||||193|133.17|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|193||||193|96.5|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193||||193|85.11|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193||||193|57.22|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193||||193|85.11|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193||||193|57.22|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|193||||193|57.22|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|193||||193|133.17|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193||||193|57.22|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|Self-pay|Self-pay|193||||193|67.55|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|193||||193|57.22|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193||||193|57.22|133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193||||193||133.17|46.85
42097750|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193||||193||133.17|46.85
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AARP [1000]|AARP [100000]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AETNA [1015]|AETNA [101529]|141||||141|62.18|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|141||||141|41.81|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS [1155]|BCBS UTHCT [115568]|141||||141|66.27|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|141||||141|58.23|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|141||||141|70.5|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|141||||141|88.83|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|141||||141|41.81|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|CIGNA [1260]|CIGNA GWH [126023]|141||||141|75|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|141||||141|97.29|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|141||||141|70.5|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|141||||141|62.18|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|141||||141|41.81|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|141||||141|62.18|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|141||||141|41.81|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|141||||141|41.81|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|141||||141|97.29|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|141||||141|41.81|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|Self-pay|Self-pay|141||||141|49.35|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|141||||141|41.81|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|141||||141|41.81|97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|141||||141||97.29|41.81
42097760|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|141||||141||97.29|41.81
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AARP [1000]|AARP [100000]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA [1015]|AETNA [101529]|86||||86|37.93|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|86||||86|25.5|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|86||||86|40.42|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|86||||86|50.35|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|86||||86|43|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|86||||86|54.18|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|86||||86|25.5|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|86||||86|75|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|86||||86|59.34|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|86||||86|43|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86||||86|37.93|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|86||||86|25.5|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|86||||86|37.93|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|86||||86|25.5|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|86||||86|25.5|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|86||||86|59.34|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|86||||86|25.5|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|Self-pay|Self-pay|86||||86|30.1|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|86||||86|25.5|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|86||||86|25.5|75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|86||||86||75|25.5
42097761|EAP|0420 - PHYSICAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|86||||86||75|25.5
4210001|EAP||HH PT ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73||88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73||88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73||88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||139.73|65.67|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|69.87|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|69.87|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|88.03|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73||88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73||88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73||88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|Self-pay|Self-pay|||||139.73|48.91|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||139.73||88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||139.73||88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73||88.03|48.91
4210001|EAP||HH PT ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||139.73|65.67|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|69.87|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|69.87|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|88.03|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|Self-pay|Self-pay|||||139.73|48.91|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73||88.03|48.91
4210002|EAP||HH PT INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||139.73|65.67|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|69.87|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|69.87|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|88.03|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|Self-pay|Self-pay|||||139.73|48.91|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73||88.03|48.91
4210003|EAP||HH PTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|AARP [1000]|AARP [100000]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|AETNA [1015]|AETNA [101529]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BCBS UTHCT [115568]|||||139.73|65.67|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||139.73|69.87|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||139.73|69.87|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||139.73|88.03|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|CIGNA [1260]|CIGNA GWH [126023]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|Self-pay|Self-pay|||||139.73|48.91|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||139.73|0|88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||139.73||88.03|48.91
4210004|EAP||HH PT MAINTENANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||139.73||88.03|48.91
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|26.62||||26.62|11.74|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.62||||26.62|7.89|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|26.62||||26.62|12.51|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.62||||26.62|13.31|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.62||||26.62|13.31|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.62||||26.62|16.77|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.62||||26.62|7.89|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|26.62||||26.62|14.64|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|26.62||||26.62|18.37|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|26.62||||26.62|13.31|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.62||||26.62|11.74|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.62||||26.62|7.89|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.62||||26.62|11.74|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.62||||26.62|7.89|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|26.62||||26.62|7.89|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|26.62||||26.62|18.37|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.62||||26.62|7.89|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|26.62||||26.62|9.32|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|26.62||||26.62|7.89|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.62||||26.62|7.89|18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.62||||26.62||18.37|7.89
42162|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.62||||26.62||18.37|7.89
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|29.28||||29.28|12.91|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.28||||29.28|8.68|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|29.28||||29.28|13.76|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.28||||29.28|14.64|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.28||||29.28|14.64|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.28||||29.28|18.45|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.28||||29.28|8.68|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|29.28||||29.28|16.1|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|29.28||||29.28|20.2|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29.28||||29.28|14.64|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.28||||29.28|12.91|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.28||||29.28|8.68|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.28||||29.28|12.91|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.28||||29.28|8.68|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|29.28||||29.28|8.68|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|29.28||||29.28|20.2|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.28||||29.28|8.68|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|29.28||||29.28|10.25|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29.28||||29.28|8.68|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.28||||29.28|8.68|20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.28||||29.28||20.2|8.68
42163|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|29.28||||29.28|12.91|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.28||||29.28|8.68|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|29.28||||29.28|13.76|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.28||||29.28|14.64|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.28||||29.28|14.64|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.28||||29.28|18.45|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.28||||29.28|8.68|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|29.28||||29.28|16.1|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|29.28||||29.28|20.2|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29.28||||29.28|14.64|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.28||||29.28|12.91|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.28||||29.28|8.68|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.28||||29.28|12.91|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.28||||29.28|8.68|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|29.28||||29.28|8.68|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|29.28||||29.28|20.2|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.28||||29.28|8.68|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|Self-pay|Self-pay|29.28||||29.28|10.25|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29.28||||29.28|8.68|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.28||||29.28|8.68|20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.28||||29.28||20.2|8.68
42164|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 75 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.28||||29.28||20.2|8.68
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.87||||0.87|0.38|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.87||||0.87|0.26|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.87||||0.87|0.41|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.87||||0.87|0.44|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.87||||0.87|0.44|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.87||||0.87|0.55|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.87||||0.87|0.26|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.87||||0.87|0.48|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.87||||0.87|0.6|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.87||||0.87|0.44|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.87||||0.87|0.38|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.87||||0.87|0.26|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.87||||0.87|0.38|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.87||||0.87|0.26|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.87||||0.87|0.26|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.87||||0.87|0.6|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.87||||0.87|0.26|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.87||||0.87|0.3|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.87||||0.87|0.26|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.87||||0.87|0.26|0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.87||||0.87||0.6|0.26
42165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREGABALIN 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.87||||0.87||0.6|0.26
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AARP [1000]|AARP [100000]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AETNA [1015]|AETNA [101529]|11.16||||11.16|4.92|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.16||||11.16|3.31|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS [1155]|BCBS UTHCT [115568]|11.16||||11.16|5.25|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.16||||11.16|5.58|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.16||||11.16|5.58|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.16||||11.16|7.03|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.16||||11.16|3.31|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|CIGNA [1260]|CIGNA GWH [126023]|11.16||||11.16|6.14|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|11.16||||11.16|7.7|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.16||||11.16|5.58|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.16||||11.16|4.92|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.16||||11.16|3.31|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.16||||11.16|4.92|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.16||||11.16|3.31|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.16||||11.16|3.31|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|11.16||||11.16|7.7|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.16||||11.16|3.31|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|Self-pay|Self-pay|11.16||||11.16|3.91|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.16||||11.16|3.31|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.16||||11.16|3.31|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|120 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.16||||11.16||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|AARP [1000]|AARP [100000]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|AETNA [1015]|AETNA [101529]|7.54||||7.54|3.33|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.54||||7.54|2.24|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|BCBS [1155]|BCBS UTHCT [115568]|7.54||||7.54|3.54|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.54||||7.54|3.77|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.54||||7.54|3.77|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.54||||7.54|4.75|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.54||||7.54|2.24|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|CIGNA [1260]|CIGNA GWH [126023]|7.54||||7.54|4.15|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.54||||7.54|5.2|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.54||||7.54|3.77|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.54||||7.54|3.33|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.54||||7.54|2.24|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.54||||7.54|3.33|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.54||||7.54|2.24|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.54||||7.54|2.24|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.54||||7.54|5.2|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.54||||7.54|2.24|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|Self-pay|Self-pay|7.54||||7.54|2.64|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.54||||7.54|2.24|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.54||||7.54|2.24|7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.54||||7.54||7.7|2.24
42219|ERX|0250 - PHARMACY-GENERAL|LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.54||||7.54||7.7|2.24
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|59.83||||59.83|26.39|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59.83||||59.83|17.74|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|59.83||||59.83|28.12|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59.83||||59.83|29.92|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59.83||||59.83|29.92|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59.83||||59.83|37.69|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59.83||||59.83|17.74|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|59.83||||59.83|32.91|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|59.83||||59.83|41.28|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|59.83||||59.83|29.92|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59.83||||59.83|26.39|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59.83||||59.83|17.74|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59.83||||59.83|26.39|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59.83||||59.83|17.74|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|59.83||||59.83|17.74|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|59.83||||59.83|41.28|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59.83||||59.83|17.74|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|Self-pay|Self-pay|59.83||||59.83|20.94|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|59.83||||59.83|17.74|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59.83||||59.83|17.74|41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59.83||||59.83||41.28|17.74
4236|ERX|0250 - PHARMACY-GENERAL|KETAMINE 10 MG/ML INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59.83||||59.83||41.28|17.74
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|35.95||||35.95|15.85|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.95||||35.95|10.66|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|35.95||||35.95|16.9|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.95||||35.95|17.98|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.95||||35.95|17.98|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.95||||35.95|22.65|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.95||||35.95|10.66|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|35.95||||35.95|19.77|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|35.95||||35.95|24.81|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35.95||||35.95|17.98|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.95||||35.95|15.85|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.95||||35.95|10.66|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.95||||35.95|15.85|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.95||||35.95|10.66|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|35.95||||35.95|10.66|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|35.95||||35.95|24.81|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.95||||35.95|10.66|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|Self-pay|Self-pay|35.95||||35.95|12.58|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35.95||||35.95|10.66|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.95||||35.95|10.66|24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.95||||35.95||24.81|10.66
4237|ERX|0250 - PHARMACY-GENERAL|KETAMINE 100 MG/ML INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.95||||35.95||24.81|10.66
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|21.77||||21.77|9.6|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.77||||21.77|6.45|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|21.77||||21.77|10.23|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.77||||21.77|10.89|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.77||||21.77|10.89|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.77||||21.77|13.72|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.77||||21.77|6.45|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|21.77||||21.77|11.97|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.77||||21.77|15.02|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.77||||21.77|10.89|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.77||||21.77|9.6|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.77||||21.77|6.45|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.77||||21.77|9.6|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.77||||21.77|6.45|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.77||||21.77|6.45|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.77||||21.77|15.02|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.77||||21.77|6.45|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|21.77||||21.77|7.62|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.77||||21.77|6.45|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.77||||21.77|6.45|15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.77||||21.77||15.02|6.45
4238|ERX|0250 - PHARMACY-GENERAL|KETAMINE 50 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.77||||21.77||15.02|6.45
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AARP [1000]|AARP [100000]|271||||271|65|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|271||||271|100.06|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AETNA [1015]|AETNA [101529]|271||||271|123.48|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|271||||271|80.35|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|271||||271|99.07|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|271||||271|99.07|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BCBS UTHCT [115568]|271||||271|127.37|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|271||||271|104.21|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|271||||271|135.5|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|271||||271|170.73|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|271||||271|80.35|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|271||||271|99.07|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA GWH [126023]|271||||271|75|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|271||||271|186.99|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|271||||271|135.5|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|271||||271|99.07|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|271||||271|123.48|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|271||||271|80.35|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|271||||271|99.07|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|271||||271|123.48|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|271||||271|80.35|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|271||||271|80.35|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|271||||271|186.99|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|271||||271|80.35|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|Self-pay|Self-pay|271||||271|94.85|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|271||||271|80.35|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|271||||271|80.35|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|271||||271|65|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|271||||271|99.07|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|271||||271|99.07|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|271||||271|65|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|271||||271|99.07|198.14|65
42497161|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION LOW COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|271||||271|198.14|198.14|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AARP [1000]|AARP [100000]|437||||437|65|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|437||||437|100.06|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AETNA [1015]|AETNA [101529]|437||||437|123.48|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|437||||437|129.57|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|437||||437|99.07|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|437||||437|99.07|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BCBS UTHCT [115568]|437||||437|205.39|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|437||||437|104.21|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|437||||437|218.5|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|437||||437|275.31|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|437||||437|129.57|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|437||||437|99.07|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA GWH [126023]|437||||437|75|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|437||||437|301.53|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|437||||437|218.5|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|437||||437|99.07|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|437||||437|123.48|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|437||||437|129.57|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|437||||437|99.07|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|437||||437|123.48|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|437||||437|129.57|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|437||||437|129.57|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|437||||437|301.53|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|437||||437|129.57|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|Self-pay|Self-pay|437||||437|152.95|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|437||||437|129.57|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|437||||437|129.57|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|437||||437|65|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|437||||437|99.07|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|437||||437|99.07|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|437||||437|65|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|437||||437|99.07|301.53|65
42497162|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION MODERATE COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|437||||437|198.14|301.53|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AARP [1000]|AARP [100000]|506||||506|65|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|506||||506|100.06|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AETNA [1015]|AETNA [101529]|506||||506|123.48|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|506||||506|150.03|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|506||||506|99.07|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|506||||506|99.07|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BCBS UTHCT [115568]|506||||506|237.82|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|506||||506|104.21|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|506||||506|253|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|506||||506|318.78|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|506||||506|150.03|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|506||||506|99.07|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA GWH [126023]|506||||506|75|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|506||||506|349.14|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|506||||506|253|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|506||||506|99.07|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|506||||506|123.48|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|506||||506|150.03|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|506||||506|99.07|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|506||||506|123.48|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|506||||506|150.03|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|506||||506|150.03|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|506||||506|349.14|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|506||||506|150.03|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|Self-pay|Self-pay|506||||506|177.1|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|506||||506|150.03|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|506||||506|150.03|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|506||||506|65|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|506||||506|99.07|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|506||||506|99.07|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|506||||506|65|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|506||||506|99.07|349.14|65
42497163|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT EVALUATION HIGH COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|506||||506|198.14|349.14|65
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AARP [1000]|AARP [100000]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AETNA [1015]|AETNA [101529]|237||||237|84.96|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237||||237|70.27|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BCBS UTHCT [115568]|237||||237|111.39|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237||||237|70.49|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237||||237|118.5|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237||||237|149.31|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237||||237|70.27|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA GWH [126023]|237||||237|75|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|237||||237|163.53|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|237||||237|118.5|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237||||237|84.96|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237||||237|70.27|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237||||237|84.96|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237||||237|70.27|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|237||||237|70.27|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|237||||237|163.53|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237||||237|70.27|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|Self-pay|Self-pay|237||||237|82.95|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|237||||237|70.27|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237||||237|70.27|163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237||||237||163.53|70.27
42497164|EAP|0424 - PHYSICAL THERAPY-EVALUATION OR REEVALUATION|HC PT RE-EVALUATION EST PLAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237||||237||163.53|70.27
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|AARP [1000]|AARP [100000]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|AETNA [1015]|AETNA [101529]|765.75||||765.75|337.7|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|765.75||||765.75|227.04|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|765.75||||765.75|359.9|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|765.75||||765.75|382.88|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|765.75||||765.75|382.88|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|765.75||||765.75|482.42|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|765.75||||765.75|227.04|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|765.75||||765.75|382.88|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|765.75||||765.75|528.37|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|765.75||||765.75|382.88|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|765.75||||765.75|337.7|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|765.75||||765.75|227.04|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|765.75||||765.75|337.7|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|765.75||||765.75|227.04|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|765.75||||765.75|227.04|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|765.75||||765.75|528.37|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|765.75||||765.75|227.04|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|Self-pay|Self-pay|765.75||||765.75|268.01|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|765.75||||765.75|227.04|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|765.75||||765.75|227.04|528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|765.75||||765.75||528.37|227.04
42622|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MEASLES,MUMPS,RUBEL,VARICEL LIV(PF)10E3-4.3-3-3.99TCID50/0.5 ML SUBCUT|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|765.75||||765.75||528.37|227.04
4300001|EAP||HH OT MAINTENANCE|1|AARP [1000]|AARP [100000]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68||88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|AETNA [1015]|AETNA [101529]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68||88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68||88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BCBS UTHCT [115568]|||||140.68|66.12|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|70.34|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|70.34|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|88.63|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68||88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|CIGNA [1260]|CIGNA GWH [126023]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68||88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68||88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|Self-pay|Self-pay|||||140.68|49.24|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||140.68||88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||140.68||88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68||88.63|49.24
4300001|EAP||HH OT MAINTENANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68||88.63|49.24
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AARP [1000]|AARP [100000]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AETNA [1015]|AETNA [101529]|214||||214|94.37|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|63.45|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS [1155]|BCBS UTHCT [115568]|214||||214|100.58|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|107|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|107|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|134.82|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|63.45|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|CIGNA [1260]|CIGNA GWH [126023]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214||||214|107|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|94.37|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|63.45|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|94.37|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|63.45|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214||||214|63.45|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|63.45|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|Self-pay|Self-pay|214||||214|74.9|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214||||214|63.45|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|63.45|147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214||147.66|63.45
43029200|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING THORAX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214||147.66|63.45
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AARP [1000]|AARP [100000]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AETNA [1015]|AETNA [101529]|296||||296|130.54|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|296||||296|87.76|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS [1155]|BCBS UTHCT [115568]|296||||296|139.12|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|296||||296|148|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|296||||296|148|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|296||||296|186.48|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|296||||296|87.76|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|CIGNA [1260]|CIGNA GWH [126023]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|296||||296|204.24|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|296||||296|148|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|296||||296|130.54|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|296||||296|87.76|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|296||||296|130.54|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|296||||296|87.76|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|296||||296|87.76|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|296||||296|204.24|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|296||||296|87.76|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|Self-pay|Self-pay|296||||296|103.6|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|296||||296|87.76|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|296||||296|87.76|204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|296||||296||204.24|87.76
43029240|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING SHOULDER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|296||||296||204.24|87.76
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AARP [1000]|AARP [100000]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AETNA [1015]|AETNA [101529]|214||||214|94.37|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|63.45|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS [1155]|BCBS UTHCT [115568]|214||||214|100.58|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|107|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|107|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|134.82|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|63.45|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|CIGNA [1260]|CIGNA GWH [126023]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214||||214|107|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|94.37|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|63.45|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|94.37|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|63.45|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214||||214|63.45|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|63.45|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|Self-pay|Self-pay|214||||214|74.9|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214||||214|63.45|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|63.45|147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214||147.66|63.45
43029260|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING ELBOW/WRIST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214||147.66|63.45
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|AARP [1000]|AARP [100000]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|AETNA [1015]|AETNA [101529]|217||||217|95.7|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|217||||217|64.34|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS [1155]|BCBS UTHCT [115568]|217||||217|101.99|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|217||||217|108.5|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|217||||217|108.5|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|217||||217|136.71|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|217||||217|64.34|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|CIGNA [1260]|CIGNA GWH [126023]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|217||||217|149.73|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|217||||217|108.5|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|217||||217|95.7|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|217||||217|64.34|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|217||||217|95.7|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|217||||217|64.34|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|217||||217|64.34|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|217||||217|149.73|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|217||||217|64.34|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|Self-pay|Self-pay|217||||217|75.95|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|217||||217|64.34|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|217||||217|64.34|149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|217||||217||149.73|64.34
43029280|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC STRAPPING HAND/FINGER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|217||||217||149.73|64.34
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AARP [1000]|AARP [100000]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AETNA [1015]|AETNA [101529]|31||||31|9.02|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|9.19|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|7.88|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|9.19|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|CIGNA [1260]|CIGNA GWH [126023]|31||||31|31|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|15.5|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|9.02|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|9.19|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|9.02|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|9.19|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|9.19|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|9.19|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|Self-pay|Self-pay|31||||31|10.85|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|9.19|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|9.19|31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31||31|7.88
43097010|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC HOT/COLD PACK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31||31|7.88
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AARP [1000]|AARP [100000]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AETNA [1015]|AETNA [101529]|45||||45|8.52|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|45||||45|13.34|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BCBS UTHCT [115568]|45||||45|21.15|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|45||||45|10.94|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|45||||45|22.5|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|45||||45|28.35|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|45||||45|13.34|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|CIGNA [1260]|CIGNA GWH [126023]|45||||45|45|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|45||||45|31.05|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|45||||45|22.5|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|45||||45|8.52|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|45||||45|13.34|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|45||||45|8.52|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|45||||45|13.34|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|45||||45|13.34|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|45||||45|31.05|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|45||||45|13.34|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|Self-pay|Self-pay|45||||45|15.75|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|45||||45|13.34|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|45||||45|13.34|45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|45||||45||45|8.52
43097018|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PARAFFIN BATH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|45||||45||45|8.52
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AARP [1000]|AARP [100000]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AETNA [1015]|AETNA [101529]|221||||221|25.94|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|221||||221|65.53|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BCBS UTHCT [115568]|221||||221|103.87|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|221||||221|23.64|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|221||||221|110.5|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|221||||221|139.23|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|221||||221|65.53|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|CIGNA [1260]|CIGNA GWH [126023]|221||||221|75|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|221||||221|152.49|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|221||||221|110.5|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|221||||221|25.94|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|221||||221|65.53|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|221||||221|25.94|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|221||||221|65.53|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|221||||221|65.53|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|221||||221|152.49|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|221||||221|65.53|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|Self-pay|Self-pay|221||||221|77.35|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|221||||221|65.53|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|221||||221|65.53|152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|221||||221||152.49|23.64
43097022|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHIRLPOOL THERAPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|221||||221||152.49|23.64
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AARP [1000]|AARP [100000]|122||||122|65|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|122||||122|14.34|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AETNA [1015]|AETNA [101529]|122||||122|20.81|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|122||||122|36.17|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|122||||122|14.2|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|122||||122|14.2|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|122||||122|57.34|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|122||||122|16.64|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|122||||122|61|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|122||||122|76.86|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|122||||122|36.17|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|122||||122|14.2|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|122||||122|75|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|122||||122|84.18|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|122||||122|61|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|122||||122|14.2|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|122||||122|20.81|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|122||||122|36.17|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|122||||122|14.2|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|122||||122|20.81|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|122||||122|36.17|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|122||||122|36.17|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|122||||122|84.18|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|122||||122|36.17|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|Self-pay|Self-pay|122||||122|42.7|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|122||||122|36.17|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|122||||122|36.17|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|122||||122|65|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|122||||122|14.2|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|122||||122|14.2|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|122||||122|65|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|122||||122|14.2|84.18|14.2
43097035|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ULTRASOUND 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|122||||122|28.4|84.18|14.2
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AARP [1000]|AARP [100000]|181||||181|65|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|181||||181|29.73|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AETNA [1015]|AETNA [101529]|181||||181|44.16|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|181||||181|53.67|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|181||||181|29.44|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|181||||181|29.44|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|181||||181|85.07|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|181||||181|38.09|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|181||||181|90.5|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|181||||181|114.03|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|181||||181|53.67|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|181||||181|29.44|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|181||||181|75|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|181||||181|124.89|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|181||||181|90.5|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|181||||181|29.44|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|181||||181|44.16|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|181||||181|53.67|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|181||||181|29.44|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|181||||181|44.16|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|181||||181|53.67|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|181||||181|53.67|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|181||||181|124.89|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|181||||181|53.67|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|Self-pay|Self-pay|181||||181|63.35|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|181||||181|53.67|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|181||||181|53.67|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|181||||181|65|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|181||||181|29.44|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|181||||181|29.44|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|181||||181|65|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|181||||181|29.44|124.89|29.44
43097110|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC EXERCISE THERAPEUTIC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|181||||181|58.88|124.89|29.44
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AARP [1000]|AARP [100000]|189||||189|65|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189|34.52|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AETNA [1015]|AETNA [101529]|189||||189|50.83|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189|56.04|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189|34.18|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189|34.18|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|43.35|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189|56.04|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189|34.18|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|75|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|94.5|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189|34.18|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|50.83|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189|56.04|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189|34.18|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|50.83|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189|56.04|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189|56.04|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189|56.04|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|Self-pay|Self-pay|189||||189|66.15|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189|56.04|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189|56.04|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189|65|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189|34.18|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189|34.18|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189|65|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189|34.18|130.41|34.18
43097112|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC NEUROMUSCULAR RE-ED 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189|68.36|130.41|34.18
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AARP [1000]|AARP [100000]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AETNA [1015]|AETNA [101529]|75||||75|42.31|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|75||||75|22.24|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|75||||75|35.25|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|75||||75|38.09|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|75||||75|37.5|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|75||||75|47.25|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|75||||75|22.24|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|75||||75|75|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|75||||75|51.75|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|75||||75|37.5|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|75||||75|42.31|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|75||||75|22.24|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|75||||75|42.31|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|75||||75|22.24|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|75||||75|22.24|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|75||||75|51.75|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|75||||75|22.24|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|Self-pay|Self-pay|75||||75|26.25|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|75||||75|22.24|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|75||||75|22.24|75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|75||||75||75|22.24
43097124|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MASSAGE THERAPY EACH 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|75||||75||75|22.24
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AARP [1000]|AARP [100000]|132||||132|65|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|132||||132|27.34|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AETNA [1015]|AETNA [101529]|132||||132|40.58|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|132||||132|39.14|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|132||||132|27.07|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|132||||132|27.07|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|132||||132|62.04|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|132||||132|34.59|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|132||||132|66|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|132||||132|83.16|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|132||||132|39.14|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|132||||132|27.07|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|132||||132|75|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|132||||132|91.08|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|132||||132|66|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|132||||132|27.07|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|132||||132|40.58|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|132||||132|39.14|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|132||||132|27.07|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|132||||132|40.58|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|132||||132|39.14|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|132||||132|39.14|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|132||||132|91.08|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|132||||132|39.14|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|Self-pay|Self-pay|132||||132|46.2|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|132||||132|39.14|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|132||||132|39.14|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|132||||132|65|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|132||||132|27.07|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|132||||132|27.07|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|132||||132|65|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|132||||132|27.07|91.08|27.07
43097140|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC MANUAL THERAPY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|132||||132|54.14|91.08|27.07
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AARP [1000]|AARP [100000]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AETNA [1015]|AETNA [101529]|59||||59|26.42|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|59||||59|17.49|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BCBS UTHCT [115568]|59||||59|27.73|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|59||||59|22.77|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|59||||59|29.5|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|59||||59|37.17|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|59||||59|17.49|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|CIGNA [1260]|CIGNA GWH [126023]|59||||59|59|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|59||||59|40.71|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|59||||59|29.5|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|59||||59|26.42|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|59||||59|17.49|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|59||||59|26.42|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|59||||59|17.49|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|59||||59|17.49|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|59||||59|40.71|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|59||||59|17.49|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|Self-pay|Self-pay|59||||59|20.65|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|59||||59|17.49|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|59||||59|17.49|59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|59||||59||59|17.49
43097150|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC PROCEDURE(S)/GROUP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|59||||59||59|17.49
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AARP [1000]|AARP [100000]|156||||156|65|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|156||||156|38.47|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AETNA [1015]|AETNA [101529]|156||||156|56.98|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|156||||156|46.25|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|156||||156|38.09|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|156||||156|38.09|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|156||||156|73.32|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|156||||156|50.35|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|156||||156|78|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|156||||156|98.28|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|156||||156|46.25|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|156||||156|38.09|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|156||||156|75|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|156||||156|107.64|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|156||||156|78|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|156||||156|38.09|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|156||||156|56.98|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|156||||156|46.25|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|156||||156|38.09|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|156||||156|56.98|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|156||||156|46.25|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|156||||156|46.25|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|156||||156|107.64|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|156||||156|46.25|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|Self-pay|Self-pay|156||||156|54.6|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|156||||156|46.25|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|156||||156|46.25|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|156||||156|65|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|156||||156|38.09|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|156||||156|38.09|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|156||||156|65|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|156||||156|38.09|107.64|38.09
43097530|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC THERAPEUTIC ACTIVITY 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|156||||156|76.18|107.64|38.09
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AARP [1000]|AARP [100000]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AETNA [1015]|AETNA [101529]|146||||146|49.3|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146||||146|43.29|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|146||||146|68.62|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146||||146|42.91|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146||||146|73|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146||||146|91.98|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146||||146|43.29|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|146||||146|75|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|146||||146|100.74|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|146||||146|73|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146||||146|49.3|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146||||146|43.29|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146||||146|49.3|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146||||146|43.29|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|146||||146|43.29|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|146||||146|100.74|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146||||146|43.29|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|Self-pay|Self-pay|146||||146|51.1|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|146||||146|43.29|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146||||146|43.29|100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146||||146||100.74|42.91
43097535|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC OT ADL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146||||146||100.74|42.91
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AARP [1000]|AARP [100000]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AETNA [1015]|AETNA [101529]|66||||66|47.23|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|66||||66|19.57|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|66||||66|31.02|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|66||||66|41.16|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|66||||66|33|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|66||||66|41.58|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|66||||66|19.57|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|66||||66|66|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|66||||66|45.54|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|66||||66|33|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|66||||66|47.23|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|66||||66|19.57|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|66||||66|47.23|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|66||||66|19.57|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|66||||66|19.57|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|66||||66|45.54|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|66||||66|19.57|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|Self-pay|Self-pay|66||||66|23.1|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|66||||66|19.57|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|66||||66|19.57|66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|66||||66||66|19.57
43097537|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC COMM/WORK REINTEGRATION 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|66||||66||66|19.57
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AARP [1000]|AARP [100000]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AETNA [1015]|AETNA [101529]|89||||89|47.76|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|89||||89|26.39|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|89||||89|41.83|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|89||||89|41.59|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|89||||89|44.5|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|89||||89|56.07|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|89||||89|26.39|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|89||||89|75|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|89||||89|61.41|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|89||||89|44.5|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|89||||89|47.76|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|89||||89|26.39|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|89||||89|47.76|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|89||||89|26.39|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|89||||89|26.39|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|89||||89|61.41|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|89||||89|26.39|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|Self-pay|Self-pay|89||||89|31.15|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|89||||89|26.39|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|89||||89|26.39|75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|89||||89||75|26.39
43097542|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WHEELCHAIR TRAIN/ASSESS 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|89||||89||75|26.39
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AARP [1000]|AARP [100000]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AETNA [1015]|AETNA [101529]|189||||189|189|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|189||||189|56.04|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BCBS UTHCT [115568]|189||||189|88.83|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|189||||189|113.84|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|189||||189|94.5|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|189||||189|119.07|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|189||||189|56.04|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|CIGNA [1260]|CIGNA GWH [126023]|189||||189|75|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|189||||189|130.41|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|189||||189|94.5|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|189||||189|189|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|189||||189|56.04|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|189||||189|189|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|189||||189|56.04|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|189||||189|56.04|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|189||||189|130.41|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|189||||189|56.04|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|Self-pay|Self-pay|189||||189|66.15|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|189||||189|56.04|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|189||||189|56.04|189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|189||||189||189|56.04
43097545|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING 1ST 2 HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|189||||189||189|56.04
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AARP [1000]|AARP [100000]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AETNA [1015]|AETNA [101529]|76||||76|76|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|76||||76|22.53|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BCBS UTHCT [115568]|76||||76|35.72|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|76||||76|57.35|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|76||||76|38|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|76||||76|47.88|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|76||||76|22.53|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|CIGNA [1260]|CIGNA GWH [126023]|76||||76|75|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|76||||76|52.44|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|76||||76|38|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|76||||76|76|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|76||||76|22.53|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|76||||76|76|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|76||||76|22.53|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|76||||76|22.53|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|76||||76|52.44|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|76||||76|22.53|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|Self-pay|Self-pay|76||||76|26.6|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|76||||76|22.53|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|76||||76|22.53|76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|76||||76||76|22.53
43097546|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC WORK HARDENING ADDL HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|76||||76||76|22.53
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AARP [1000]|AARP [100000]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AETNA [1015]|AETNA [101529]|193||||193|85.11|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193||||193|57.22|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|193||||193|90.71|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193||||193|46.85|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193||||193|96.5|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193||||193|121.59|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193||||193|57.22|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|193||||193|75|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|193||||193|133.17|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|193||||193|96.5|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193||||193|85.11|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193||||193|57.22|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193||||193|85.11|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193||||193|57.22|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|193||||193|57.22|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|193||||193|133.17|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193||||193|57.22|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|Self-pay|Self-pay|193||||193|67.55|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|193||||193|57.22|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193||||193|57.22|133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193||||193||133.17|46.85
43097750|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PERFORMANCE TEST 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193||||193||133.17|46.85
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AARP [1000]|AARP [100000]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AETNA [1015]|AETNA [101529]|141||||141|62.18|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|141||||141|41.81|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|141||||141|66.27|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|141||||141|58.23|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|141||||141|70.5|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|141||||141|88.83|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|141||||141|41.81|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|141||||141|75|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|141||||141|97.29|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|141||||141|70.5|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|141||||141|62.18|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|141||||141|41.81|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|141||||141|62.18|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|141||||141|41.81|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|141||||141|41.81|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|141||||141|97.29|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|141||||141|41.81|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|Self-pay|Self-pay|141||||141|49.35|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|141||||141|41.81|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|141||||141|41.81|97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|141||||141||97.29|41.81
43097760|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC ORTHOTIC MGMT&TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|141||||141||97.29|41.81
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AARP [1000]|AARP [100000]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AETNA [1015]|AETNA [101529]|86||||86|37.93|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|86||||86|25.5|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|86||||86|40.42|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|86||||86|50.35|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|86||||86|43|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|86||||86|54.18|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|86||||86|25.5|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|86||||86|75|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|86||||86|59.34|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|86||||86|43|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86||||86|37.93|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|86||||86|25.5|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|86||||86|37.93|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|86||||86|25.5|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|86||||86|25.5|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|86||||86|59.34|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|86||||86|25.5|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|Self-pay|Self-pay|86||||86|30.1|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|86||||86|25.5|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|86||||86|25.5|75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|86||||86||75|25.5
43097761|EAP|0430 - OCCUPATIONAL THERAPY-GENERAL|HC PROSTHETIC TRAINING INIT ENC 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|86||||86||75|25.5
4310001|EAP||HH OT ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68||88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68||88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68||88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||140.68|66.12|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|70.34|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|70.34|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|88.63|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68||88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68||88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68||88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|Self-pay|Self-pay|||||140.68|49.24|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||140.68||88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||140.68||88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68||88.63|49.24
4310001|EAP||HH OT ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||140.68|66.12|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|70.34|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|70.34|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|88.63|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|Self-pay|Self-pay|||||140.68|49.24|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68||88.63|49.24
4310002|EAP||HH OT INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||140.68|66.12|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||140.68|70.34|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||140.68|70.34|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||140.68|88.63|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|Self-pay|Self-pay|||||140.68|49.24|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||140.68|0|88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||140.68||88.63|49.24
4310003|EAP||HH OTA ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||140.68||88.63|49.24
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5|6.98|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|5.62|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|3.11|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|5.62|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|5.62|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5|6.98|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5|6.98|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|AARP [1000]|AARP [100000]|12.4||||12.4|5.58|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.4||||12.4||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|12.4||||12.4|5.62|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.4||||12.4|3.68|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.4||||12.4||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.4||||12.4||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BCBS UTHCT [115568]|12.4||||12.4|5.83|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.4||||12.4|0|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.4||||12.4|6.2|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.4||||12.4|7.81|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.4||||12.4|3.68|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.4||||12.4||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|CIGNA [1260]|CIGNA GWH [126023]|12.4||||12.4|6.82|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.4||||12.4|8.56|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.4||||12.4|3.11|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.4||||12.4||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.4||||12.4|5.62|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.4||||12.4|3.68|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.4||||12.4||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.4||||12.4|5.62|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.4||||12.4|3.68|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.4||||12.4|3.68|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.4||||12.4|8.56|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.4||||12.4|3.68|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|Self-pay|Self-pay|12.4||||12.4|4.34|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.4||||12.4|3.68|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.4||||12.4|3.68|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.4||||12.4|5.58|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.4||||12.4||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.4||||12.4||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.4||||12.4|5.58|10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.4||||12.4||10.7|3.11
4318|ERX|0258 - PHARMACY-IV SOLUTIONS|LACTATED RINGERS INTRAVENOUS SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.4||||12.4||10.7|3.11
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AARP [1000]|AARP [100000]|348||||348|65|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|348||||348|97.03|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AETNA [1015]|AETNA [101529]|348||||348|131.16|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|348||||348|103.18|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|348||||348|96.07|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|348||||348|96.07|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BCBS UTHCT [115568]|348||||348|163.56|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|348||||348|112.52|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|348||||348|174|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|348||||348|219.24|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|348||||348|103.18|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|348||||348|96.07|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|CIGNA [1260]|CIGNA GWH [126023]|348||||348|75|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|348||||348|240.12|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|348||||348|174|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|348||||348|96.07|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|348||||348|131.16|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|348||||348|103.18|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|348||||348|96.07|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|348||||348|131.16|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|348||||348|103.18|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|348||||348|103.18|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|348||||348|240.12|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|348||||348|103.18|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|Self-pay|Self-pay|348||||348|121.8|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|348||||348|103.18|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|348||||348|103.18|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|348||||348|65|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|348||||348|96.07|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|348||||348|96.07|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|348||||348|65|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|348||||348|96.07|240.12|65
43497165|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION LOW COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|348||||348|192.14|240.12|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AARP [1000]|AARP [100000]|419||||419|65|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|419||||419|97.03|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AETNA [1015]|AETNA [101529]|419||||419|130.66|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|419||||419|124.23|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|419||||419|96.07|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|419||||419|96.07|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BCBS UTHCT [115568]|419||||419|196.93|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|419||||419|112.52|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|419||||419|209.5|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|419||||419|263.97|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|419||||419|124.23|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|419||||419|96.07|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|CIGNA [1260]|CIGNA GWH [126023]|419||||419|75|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|419||||419|289.11|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|419||||419|209.5|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|419||||419|96.07|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|419||||419|130.66|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|419||||419|124.23|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|419||||419|96.07|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|419||||419|130.66|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|419||||419|124.23|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|419||||419|124.23|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|419||||419|289.11|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|419||||419|124.23|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|Self-pay|Self-pay|419||||419|146.65|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|419||||419|124.23|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|419||||419|124.23|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|419||||419|65|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|419||||419|96.07|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|419||||419|96.07|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|419||||419|65|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|419||||419|96.07|289.11|65
43497166|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION MODERATE COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|419||||419|192.14|289.11|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AARP [1000]|AARP [100000]|489||||489|65|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|489||||489|97.03|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AETNA [1015]|AETNA [101529]|489||||489|130.66|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|489||||489|144.99|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|489||||489|96.07|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|489||||489|96.07|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BCBS UTHCT [115568]|489||||489|229.83|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|489||||489|112.52|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|489||||489|244.5|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|489||||489|308.07|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|489||||489|144.99|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|489||||489|96.07|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|CIGNA [1260]|CIGNA GWH [126023]|489||||489|75|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|489||||489|337.41|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|489||||489|244.5|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|489||||489|96.07|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|489||||489|130.66|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|489||||489|144.99|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|489||||489|96.07|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|489||||489|130.66|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|489||||489|144.99|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|489||||489|144.99|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|489||||489|337.41|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|489||||489|144.99|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|Self-pay|Self-pay|489||||489|171.15|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|489||||489|144.99|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|489||||489|144.99|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|489||||489|65|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|489||||489|96.07|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|489||||489|96.07|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|489||||489|65|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|489||||489|96.07|337.41|65
43497167|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT EVALUATION HIGH COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|489||||489|192.14|337.41|65
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AARP [1000]|AARP [100000]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AETNA [1015]|AETNA [101529]|237||||237|90.58|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|237||||237|70.27|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BCBS UTHCT [115568]|237||||237|111.39|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|237||||237|76.63|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|237||||237|118.5|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|237||||237|149.31|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|237||||237|70.27|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|CIGNA [1260]|CIGNA GWH [126023]|237||||237|75|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|237||||237|163.53|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|237||||237|118.5|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|237||||237|90.58|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|237||||237|70.27|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|237||||237|90.58|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|237||||237|70.27|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|237||||237|70.27|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|237||||237|163.53|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|237||||237|70.27|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|Self-pay|Self-pay|237||||237|82.95|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|237||||237|70.27|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|237||||237|70.27|163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|237||||237||163.53|70.27
43497168|EAP|0434 - OCCUPATIONAL THERAPY-EVALUATION OR REEVALUA|HC OT RE-EVALUATION EST PLAN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|237||||237||163.53|70.27
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.34||||1.34|0.59|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.34||||1.34|0.4|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.34||||1.34|0.63|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.34||||1.34|0.67|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.34||||1.34|0.67|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.34||||1.34|0.84|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.34||||1.34|0.4|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.34||||1.34|0.74|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.34||||1.34|0.92|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.34||||1.34|0.67|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.34||||1.34|0.59|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.34||||1.34|0.4|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.34||||1.34|0.59|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.34||||1.34|0.4|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.34||||1.34|0.4|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.34||||1.34|0.92|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.34||||1.34|0.4|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|1.34||||1.34|0.47|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.34||||1.34|0.4|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.34||||1.34|0.4|0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.34||||1.34||0.92|0.4
435|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.34||||1.34||0.92|0.4
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|36.12||||36.12|15.93|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.12||||36.12|10.71|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|36.12||||36.12|16.98|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.12||||36.12|18.06|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.12||||36.12|18.06|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.12||||36.12|22.76|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.12||||36.12|10.71|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|36.12||||36.12|19.87|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|36.12||||36.12|24.92|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|36.12||||36.12|18.06|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.12||||36.12|15.93|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.12||||36.12|10.71|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.12||||36.12|15.93|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36.12||||36.12|10.71|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|36.12||||36.12|10.71|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|36.12||||36.12|24.92|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.12||||36.12|10.71|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|Self-pay|Self-pay|36.12||||36.12|12.64|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|36.12||||36.12|10.71|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.12||||36.12|10.71|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36.12||||36.12||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|AARP [1000]|AARP [100000]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|AETNA [1015]|AETNA [101529]|433.38||||433.38|191.12|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|433.38||||433.38|128.5|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|BCBS [1155]|BCBS UTHCT [115568]|433.38||||433.38|203.69|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|433.38||||433.38|216.69|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|433.38||||433.38|216.69|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|433.38||||433.38|273.03|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|433.38||||433.38|128.5|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|CIGNA [1260]|CIGNA GWH [126023]|433.38||||433.38|238.36|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|433.38||||433.38|299.03|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|433.38||||433.38|216.69|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|433.38||||433.38|191.12|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|433.38||||433.38|128.5|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|433.38||||433.38|191.12|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|433.38||||433.38|128.5|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|433.38||||433.38|128.5|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|433.38||||433.38|299.03|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|433.38||||433.38|128.5|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|Self-pay|Self-pay|433.38||||433.38|151.68|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|433.38||||433.38|128.5|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|433.38||||433.38|128.5|299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|433.38||||433.38||299.03|10.71
43556|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIGOXIN 50 MCG/ML (0.05 MG/ML) ORAL SOLUTION|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|433.38||||433.38||299.03|10.71
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.78||||1.78|0.78|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.78||||1.78|0.53|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.78||||1.78|0.84|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.78||||1.78|0.89|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.78||||1.78|0.89|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.78||||1.78|1.12|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.78||||1.78|0.53|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.78||||1.78|0.98|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.78||||1.78|1.23|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.78||||1.78|0.89|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.78||||1.78|0.78|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.78||||1.78|0.53|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.78||||1.78|0.78|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.78||||1.78|0.53|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.78||||1.78|0.53|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.78||||1.78|1.23|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.78||||1.78|0.53|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.78||||1.78|0.62|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.78||||1.78|0.53|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.78||||1.78|0.53|1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.78||||1.78||1.23|0.53
436|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMITRIPTYLINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.78||||1.78||1.23|0.53
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|AARP [1000]|AARP [100000]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|AETNA [1015]|AETNA [101529]|1.36||||1.36|0.6|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.36||||1.36|0.4|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|BCBS [1155]|BCBS UTHCT [115568]|1.36||||1.36|0.64|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.36||||1.36|0.68|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.36||||1.36|0.68|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.36||||1.36|0.86|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.36||||1.36|0.4|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|CIGNA [1260]|CIGNA GWH [126023]|1.36||||1.36|0.75|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.36||||1.36|0.94|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.36||||1.36|0.68|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.36||||1.36|0.6|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.36||||1.36|0.4|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.36||||1.36|0.6|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.36||||1.36|0.4|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.36||||1.36|0.4|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.36||||1.36|0.94|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.36||||1.36|0.4|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|Self-pay|Self-pay|1.36||||1.36|0.48|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.36||||1.36|0.4|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.36||||1.36|0.4|0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.36||||1.36||0.94|0.4
439|ERX|0250 - PHARMACY-GENERAL|AMMONIA AROMATIC 15 % (W/V) SOLUTION FOR INHALATION|1 ampule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.36||||1.36||0.94|0.4
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|AARP [1000]|AARP [100000]|62||||62|17.14|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62||||62||42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|AETNA [1015]|AETNA [101529]|62||||62|15.26|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62||||62|18.38|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62||||62||42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|62||||62||42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|62||||62|29.14|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|62||||62|0|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62||||62|31|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|62||||62|39.06|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|62||||62|18.38|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62||||62||42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|62||||62|34.1|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|62||||62|42.78|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|62||||62|3.41|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|62||||62||42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62||||62|15.26|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62||||62|18.38|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62||||62||42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62||||62|15.26|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|62||||62|18.38|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|62||||62|18.38|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|62||||62|42.78|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62||||62|18.38|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|Self-pay|Self-pay|62||||62|21.7|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|62||||62|18.38|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|62||||62|18.38|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62||||62|17.14|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|62||||62||42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|62||||62||42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62||||62|17.14|42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62||||62||42.78|3.41
4392|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|62||||62||42.78|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|AARP [1000]|AARP [100000]|58.75||||58.75|58.75|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|58.75||||58.75||58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|AETNA [1015]|AETNA [101529]|58.75||||58.75|53.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|58.75||||58.75|17.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|58.75||||58.75||58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|58.75||||58.75||58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|BCBS [1155]|BCBS UTHCT [115568]|58.75||||58.75|27.61|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|58.75||||58.75|0|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|58.75||||58.75|29.38|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|58.75||||58.75|37.01|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|58.75||||58.75|17.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|58.75||||58.75||58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|CIGNA [1260]|CIGNA GWH [126023]|58.75||||58.75|32.31|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|58.75||||58.75|40.54|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|58.75||||58.75|3.41|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|58.75||||58.75||58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|58.75||||58.75|53.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|58.75||||58.75|17.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|58.75||||58.75||58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|58.75||||58.75|53.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|58.75||||58.75|17.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|58.75||||58.75|17.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|58.75||||58.75|40.54|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|58.75||||58.75|17.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|Self-pay|Self-pay|58.75||||58.75|20.56|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|58.75||||58.75|17.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|58.75||||58.75|17.42|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|58.75||||58.75|58.75|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|58.75||||58.75||58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|58.75||||58.75||58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|58.75||||58.75|58.75|58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|58.75||||58.75||58.75|3.41
4393|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION|17.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|58.75||||58.75||58.75|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|AARP [1000]|AARP [100000]|31||||31|8.57|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31||21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|AETNA [1015]|AETNA [101529]|31||||31|7.63|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|9.19|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31||21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31||21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|0|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|9.19|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31||21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA [1260]|CIGNA GWH [126023]|31||||31|17.05|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|3.41|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31||21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|7.63|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|9.19|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31||21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|7.63|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|9.19|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|9.19|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|9.19|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|Self-pay|Self-pay|31||||31|10.85|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|9.19|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|9.19|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31|8.57|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31||21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31||21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31|8.57|21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31||21.39|3.41
4394|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31||21.39|3.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|8.13||||8.13|3.59|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.13||||8.13|2.41|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|8.13||||8.13|3.82|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.13||||8.13|4.07|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.13||||8.13|4.07|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.13||||8.13|5.12|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.13||||8.13|2.41|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|8.13||||8.13|4.47|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.13||||8.13|5.61|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.13||||8.13|4.07|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.13||||8.13|3.59|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.13||||8.13|2.41|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.13||||8.13|3.59|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.13||||8.13|2.41|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.13||||8.13|2.41|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.13||||8.13|5.61|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.13||||8.13|2.41|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|Self-pay|Self-pay|8.13||||8.13|2.85|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.13||||8.13|2.41|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.13||||8.13|2.41|5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.13||||8.13||5.61|2.41
4398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEUCOVORIN CALCIUM 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.13||||8.13||5.61|2.41
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AARP [1000]|AARP [100000]|347||||347|65|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|347||||347|76.8|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AETNA [1015]|AETNA [101529]|347||||347|96.53|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|347||||347|102.89|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|347||||347|76.04|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|347||||347|76.04|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BCBS UTHCT [115568]|347||||347|163.09|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|347||||347|97.2|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|347||||347|173.5|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|347||||347|218.61|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|347||||347|102.89|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|347||||347|76.04|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|CIGNA [1260]|CIGNA GWH [126023]|347||||347|75|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|347||||347|239.43|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|347||||347|173.5|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|347||||347|76.04|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|347||||347|96.53|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|347||||347|102.89|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|347||||347|76.04|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|347||||347|96.53|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|347||||347|102.89|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|347||||347|102.89|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|347||||347|239.43|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|347||||347|102.89|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|Self-pay|Self-pay|347||||347|121.45|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|347||||347|102.89|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|347||||347|102.89|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|347||||347|65|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|347||||347|76.04|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|347||||347|76.04|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|347||||347|65|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|347||||347|76.04|239.43|65
44092507|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TX SPEECH/LANGUAGE/VOICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|347||||347|152.08|239.43|65
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AARP [1000]|AARP [100000]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AETNA [1015]|AETNA [101529]|219||||219|96.58|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|219||||219|64.93|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BCBS UTHCT [115568]|219||||219|102.93|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|219||||219|106.4|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|219||||219|109.5|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|219||||219|137.97|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|219||||219|64.93|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|CIGNA [1260]|CIGNA GWH [126023]|219||||219|75|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|GROUP PENSION ADMIN [1450]|GPA [145000]|219||||219|151.11|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|219||||219|109.5|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|219||||219|96.58|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|219||||219|64.93|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|219||||219|96.58|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|219||||219|64.93|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|219||||219|64.93|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|PHCS [1780]|PHCS MULTIPLAN [178000]|219||||219|151.11|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|219||||219|64.93|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|Self-pay|Self-pay|219||||219|76.65|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|219||||219|64.93|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|219||||219|64.93|151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|219||||219||151.11|64.93
44092526|EAP|0440 - SPEECH THERAPY-LANGUAGE PATHOLOGY-GENERAL|HC TREATMENT SWALLOW|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|219||||219||151.11|64.93
4410001|EAP||HH SLP ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||151.85||95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||151.85||95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||151.85||95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||151.85|71.37|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||151.85|75.93|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||151.85|75.93|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||151.85|95.67|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||151.85||95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||151.85||95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||151.85||95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|Self-pay|Self-pay|||||151.85|53.15|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||151.85||95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||151.85||95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||151.85|0|95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||151.85||95.67|53.15
4410001|EAP||HH SLP ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||151.85|71.37|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||151.85|75.93|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||151.85|75.93|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||151.85|95.67|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|Self-pay|Self-pay|||||151.85|53.15|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||151.85|0|95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||151.85||95.67|53.15
4410002|EAP||HH SLP INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|AARP [1000]|AARP [100000]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|AETNA [1015]|AETNA [101529]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BCBS UTHCT [115568]|||||151.85|71.37|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||151.85|75.93|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||151.85|75.93|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||151.85|95.67|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|CIGNA [1260]|CIGNA GWH [126023]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|Self-pay|Self-pay|||||151.85|53.15|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||151.85|0|95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||151.85||95.67|53.15
4410003|EAP||HH SLP MAINTENANCE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||151.85||95.67|53.15
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.7||||0.7|0.31|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.7||||0.7|0.21|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.7||||0.7|0.33|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.7||||0.7|0.35|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.7||||0.7|0.35|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.7||||0.7|0.44|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.7||||0.7|0.21|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.7||||0.7|0.39|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.7||||0.7|0.48|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.7||||0.7|0.35|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.7||||0.7|0.31|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.7||||0.7|0.21|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.7||||0.7|0.31|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.7||||0.7|0.21|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.7||||0.7|0.21|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.7||||0.7|0.48|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.7||||0.7|0.21|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|Self-pay|Self-pay|0.7||||0.7|0.24|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.7||||0.7|0.21|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.7||||0.7|0.21|0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.7||||0.7||0.48|0.21
4420|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 25 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.7||||0.7||0.48|0.21
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.55||||1.55|0.68|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.55||||1.55|0.46|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.55||||1.55|0.73|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.55||||1.55|0.78|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.55||||1.55|0.78|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.55||||1.55|0.98|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.55||||1.55|0.46|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.55||||1.55|0.85|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.55||||1.55|1.07|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.55||||1.55|0.78|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.55||||1.55|0.68|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.55||||1.55|0.46|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.55||||1.55|0.68|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.55||||1.55|0.46|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.55||||1.55|0.46|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.55||||1.55|1.07|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.55||||1.55|0.46|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|Self-pay|Self-pay|1.55||||1.55|0.54|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.55||||1.55|0.46|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.55||||1.55|0.46|1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.55||||1.55||1.07|0.46
4421|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 50 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.55||||1.55||1.07|0.46
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.71||||1.71|0.75|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.71||||1.71|0.51|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.71||||1.71|0.8|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.71||||1.71|0.86|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.71||||1.71|0.86|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.71||||1.71|1.08|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.71||||1.71|0.51|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.71||||1.71|0.94|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.71||||1.71|1.18|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.71||||1.71|0.86|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.71||||1.71|0.75|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.71||||1.71|0.51|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.71||||1.71|0.75|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.71||||1.71|0.51|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.71||||1.71|0.51|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.71||||1.71|1.18|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.71||||1.71|0.51|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|Self-pay|Self-pay|1.71||||1.71|0.6|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.71||||1.71|0.51|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.71||||1.71|0.51|1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.71||||1.71||1.18|0.51
4422|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 75 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.71||||1.71||1.18|0.51
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.75||||1.75|0.77|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.75||||1.75|0.52|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.75||||1.75|0.82|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.75||||1.75|0.88|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.75||||1.75|0.88|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.75||||1.75|1.1|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.75||||1.75|0.52|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.75||||1.75|0.96|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.75||||1.75|1.21|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.75||||1.75|0.88|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.75||||1.75|0.77|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.75||||1.75|0.52|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.75||||1.75|0.77|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.75||||1.75|0.52|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.75||||1.75|0.52|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.75||||1.75|1.21|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.75||||1.75|0.52|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|Self-pay|Self-pay|1.75||||1.75|0.61|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.75||||1.75|0.52|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.75||||1.75|0.52|1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.75||||1.75||1.21|0.52
4423|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 100 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.75||||1.75||1.21|0.52
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.05||||1.05|0.46|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.05||||1.05|0.31|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.05||||1.05|0.49|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.05||||1.05|0.53|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.05||||1.05|0.53|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.05||||1.05|0.66|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.05||||1.05|0.31|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.05||||1.05|0.58|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.05||||1.05|0.72|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.05||||1.05|0.53|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.05||||1.05|0.46|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.05||||1.05|0.31|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.05||||1.05|0.46|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.05||||1.05|0.31|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.05||||1.05|0.31|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.05||||1.05|0.72|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.05||||1.05|0.31|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|Self-pay|Self-pay|1.05||||1.05|0.37|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.05||||1.05|0.31|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.05||||1.05|0.31|0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.05||||1.05||0.72|0.31
4424|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 125 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.05||||1.05||0.72|0.31
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.76||||1.76|0.78|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.76||||1.76|0.52|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.76||||1.76|0.83|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.76||||1.76|0.88|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.76||||1.76|0.88|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.76||||1.76|1.11|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.76||||1.76|0.52|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.76||||1.76|0.97|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.76||||1.76|1.21|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.76||||1.76|0.88|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.76||||1.76|0.78|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.76||||1.76|0.52|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.76||||1.76|0.78|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.76||||1.76|0.52|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.76||||1.76|0.52|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.76||||1.76|1.21|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.76||||1.76|0.52|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|Self-pay|Self-pay|1.76||||1.76|0.62|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.76||||1.76|0.52|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.76||||1.76|0.52|1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.76||||1.76||1.21|0.52
4425|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVOTHYROXINE 150 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.76||||1.76||1.21|0.52
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AARP [1000]|AARP [100000]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AETNA [1015]|AETNA [101529]|350||||350|154.35|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|350||||350|103.78|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BCBS UTHCT [115568]|350||||350|164.5|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|350||||350|147.12|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|350||||350|175|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|350||||350|220.5|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|350||||350|103.78|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|CIGNA [1260]|CIGNA GWH [126023]|350||||350|75|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|350||||350|241.5|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|350||||350|175|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|350||||350|154.35|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|350||||350|103.78|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|350||||350|154.35|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|350||||350|103.78|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|350||||350|103.78|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|350||||350|241.5|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|350||||350|103.78|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|Self-pay|Self-pay|350||||350|122.5|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|350||||350|103.78|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|350||||350|103.78|241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|350||||350||241.5|75
44296125|EAP|0442 - SPEECH THERAPY-LANGUAGE PATHOLOGY-HOURLY CH|HC COGNITIVE TEST PER HR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|350||||350||241.5|75
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|AARP [1000]|AARP [100000]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|AETNA [1015]|AETNA [101529]|331.55||||331.55|146.21|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|331.55||||331.55|98.3|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|BCBS [1155]|BCBS UTHCT [115568]|331.55||||331.55|155.83|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|331.55||||331.55|165.78|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|331.55||||331.55|165.78|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|331.55||||331.55|208.88|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|331.55||||331.55|98.3|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|CIGNA [1260]|CIGNA GWH [126023]|331.55||||331.55|182.35|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|331.55||||331.55|228.77|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|331.55||||331.55|165.78|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|331.55||||331.55|146.21|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|331.55||||331.55|98.3|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|331.55||||331.55|146.21|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|331.55||||331.55|98.3|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|331.55||||331.55|98.3|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|331.55||||331.55|228.77|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|331.55||||331.55|98.3|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|Self-pay|Self-pay|331.55||||331.55|116.04|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|331.55||||331.55|98.3|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|331.55||||331.55|98.3|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|331.55||||331.55||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AARP [1000]|AARP [100000]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AETNA [1015]|AETNA [101529]|21.7||||21.7|9.57|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.7||||21.7|6.43|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BCBS UTHCT [115568]|21.7||||21.7|10.2|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.7||||21.7|10.85|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.7||||21.7|10.85|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.7||||21.7|13.67|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.7||||21.7|6.43|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|CIGNA [1260]|CIGNA GWH [126023]|21.7||||21.7|11.94|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.7||||21.7|14.97|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.7||||21.7|10.85|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.7||||21.7|9.57|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.7||||21.7|6.43|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.7||||21.7|9.57|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.7||||21.7|6.43|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.7||||21.7|6.43|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.7||||21.7|14.97|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.7||||21.7|6.43|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|Self-pay|Self-pay|21.7||||21.7|7.59|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.7||||21.7|6.43|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.7||||21.7|6.43|228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.7||||21.7||228.77|6.43
4448|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 2 % MUCOSAL JELLY|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.7||||21.7||228.77|6.43
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AARP [1000]|AARP [100000]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AETNA [1015]|AETNA [101529]|263||||263|137.59|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|263||||263|77.98|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BCBS UTHCT [115568]|263||||263|123.61|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|263||||263|141.42|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|263||||263|131.5|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|263||||263|165.69|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|263||||263|77.98|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|CIGNA [1260]|CIGNA GWH [126023]|263||||263|75|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|263||||263|181.47|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|263||||263|131.5|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|263||||263|137.59|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|263||||263|77.98|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|263||||263|137.59|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|263||||263|77.98|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|263||||263|77.98|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|263||||263|181.47|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|263||||263|77.98|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|Self-pay|Self-pay|263||||263|92.05|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|263||||263|77.98|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|263||||263|77.98|181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|263||||263||181.47|75
44492521|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVALUATION OF SPEECH FLUENCY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|263||||263||181.47|75
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AARP [1000]|AARP [100000]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AETNA [1015]|AETNA [101529]|214||||214|112.06|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214||||214|63.45|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BCBS UTHCT [115568]|214||||214|100.58|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214||||214|113.84|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214||||214|107|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214||||214|134.82|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214||||214|63.45|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|CIGNA [1260]|CIGNA GWH [126023]|214||||214|75|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|214||||214|147.66|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214||||214|107|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214||||214|112.06|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214||||214|63.45|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214||||214|112.06|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214||||214|63.45|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|214||||214|63.45|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|214||||214|147.66|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214||||214|63.45|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|Self-pay|Self-pay|214||||214|74.9|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214||||214|63.45|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214||||214|63.45|147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214||||214||147.66|63.45
44492522|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SPEECH SOUND PRODUCTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214||||214||147.66|63.45
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AARP [1000]|AARP [100000]|443||||443|65|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|443||||443|230.97|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AETNA [1015]|AETNA [101529]|443||||443|236.14|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|443||||443|131.35|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|443||||443|228.68|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|443||||443|228.68|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BCBS UTHCT [115568]|443||||443|208.21|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|443||||443|245.2|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|443||||443|221.5|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|443||||443|279.09|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|443||||443|131.35|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|443||||443|228.68|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|CIGNA [1260]|CIGNA GWH [126023]|443||||443|75|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|443||||443|305.67|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|443||||443|221.5|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|443||||443|228.68|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|443||||443|236.14|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|443||||443|131.35|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|443||||443|228.68|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|443||||443|236.14|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|443||||443|131.35|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|443||||443|131.35|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|443||||443|305.67|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|443||||443|131.35|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|Self-pay|Self-pay|443||||443|155.05|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|443||||443|131.35|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|443||||443|131.35|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|443||||443|65|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|443||||443|228.68|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|443||||443|228.68|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|443||||443|65|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|443||||443|228.68|457.36|65
44492523|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC SPEECH SOUND LANG COMPREHEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|443||||443|457.36|457.36|65
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AARP [1000]|AARP [100000]|210||||210|65|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|210||||210|109.91|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AETNA [1015]|AETNA [101529]|210||||210|109.46|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|210||||210|62.27|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|210||||210|108.82|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|210||||210|108.82|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BCBS UTHCT [115568]|210||||210|98.7|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|210||||210|109.02|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|210||||210|105|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|210||||210|132.3|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|210||||210|62.27|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|210||||210|108.82|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|CIGNA [1260]|CIGNA GWH [126023]|210||||210|75|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|210||||210|144.9|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|210||||210|105|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|210||||210|108.82|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|210||||210|109.46|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|210||||210|62.27|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|210||||210|108.82|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|210||||210|109.46|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|210||||210|62.27|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|210||||210|62.27|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|210||||210|144.9|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|210||||210|62.27|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|Self-pay|Self-pay|210||||210|73.5|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|210||||210|62.27|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|210||||210|62.27|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|210||||210|65|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|210||||210|108.82|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|210||||210|108.82|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|210||||210|65|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|210||||210|108.82|217.64|62.27
44492524|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC BEHAVRAL QUALIT ANALYS VOICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|210||||210|217.64|217.64|62.27
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AARP [1000]|AARP [100000]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AETNA [1015]|AETNA [101529]|572||||572|252.25|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|572||||572|169.6|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS [1155]|BCBS UTHCT [115568]|572||||572|268.84|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|572||||572|89.32|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|572||||572|286|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|572||||572|360.36|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|572||||572|169.6|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|CIGNA [1260]|CIGNA GWH [126023]|572||||572|75|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|572||||572|394.68|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|572||||572|286|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|572||||572|252.25|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|572||||572|169.6|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|572||||572|252.25|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|572||||572|169.6|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|572||||572|169.6|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|572||||572|394.68|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|572||||572|169.6|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|Self-pay|Self-pay|572||||572|200.2|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|572||||572|169.6|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|572||||572|169.6|394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|572||||572||394.68|75
44492597|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL FOR USE &/OR FITTING VOICE PROSTH DEVICE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|572||||572||394.68|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AARP [1000]|AARP [100000]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AETNA [1015]|AETNA [101529]|346||||346|152.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|346||||346|102.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BCBS UTHCT [115568]|346||||346|162.62|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|346||||346|90.19|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|346||||346|173|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|346||||346|217.98|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|346||||346|102.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|CIGNA [1260]|CIGNA GWH [126023]|346||||346|75|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|346||||346|238.74|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|346||||346|173|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|346||||346|152.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|346||||346|102.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|346||||346|152.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|346||||346|102.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|346||||346|102.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|346||||346|238.74|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|346||||346|102.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|Self-pay|Self-pay|346||||346|121.1|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|346||||346|102.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|346||||346|102.59|238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|346||||346||238.74|75
44492610|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW FUNCTION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|346||||346||238.74|75
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AARP [1000]|AARP [100000]|500||||500|65|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|500||||500|91.49|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AETNA [1015]|AETNA [101529]|500||||500|220.5|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|500||||500|148.25|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|500||||500|90.58|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|500||||500|90.58|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BCBS UTHCT [115568]|500||||500|235|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|500||||500|108.58|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|500||||500|250|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|500||||500|315|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|500||||500|148.25|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|500||||500|90.58|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|CIGNA [1260]|CIGNA GWH [126023]|500||||500|75|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|500||||500|345|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|500||||500|250|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|500||||500|90.58|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|500||||500|220.5|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|500||||500|148.25|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|500||||500|90.58|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|500||||500|220.5|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|500||||500|148.25|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|500||||500|148.25|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|500||||500|345|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|500||||500|148.25|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|Self-pay|Self-pay|500||||500|175|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|500||||500|148.25|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|500||||500|148.25|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|500||||500|65|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|500||||500|90.58|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|500||||500|90.58|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|500||||500|65|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|500||||500|90.58|345|65
44492611|EAP|0444 - SPEECH THERAPY-LANGUAGE PATHOLOGY-EVALUATIO|HC EVAL SWALLOW VIDEO/CINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|500||||500|181.16|345|65
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AARP [1000]|AARP [100000]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|124||||124|54.68|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|124||||124|36.77|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|124||||124|58.28|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|124||||124|62|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|124||||124|62|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|124||||124|78.12|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|124||||124|36.77|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|124||||124|68.2|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|124||||124|85.56|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|124||||124|62|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|124||||124|54.68|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|124||||124|36.77|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|124||||124|54.68|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|124||||124|36.77|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|124||||124|36.77|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|124||||124|85.56|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|124||||124|36.77|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|Self-pay|Self-pay|124||||124|43.4|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|124||||124|36.77|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|124||||124|36.77|85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|124||||124||85.56|36.77
4450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|124||||124||85.56|36.77
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|6.58||||6.58|2.9|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.58||||6.58|1.95|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|6.58||||6.58|3.09|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.58||||6.58|3.29|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.58||||6.58|3.29|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.58||||6.58|4.15|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.58||||6.58|1.95|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|6.58||||6.58|3.62|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.58||||6.58|4.54|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.58||||6.58|3.29|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.58||||6.58|2.9|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.58||||6.58|1.95|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.58||||6.58|2.9|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.58||||6.58|1.95|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.58||||6.58|1.95|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.58||||6.58|4.54|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.58||||6.58|1.95|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|Self-pay|Self-pay|6.58||||6.58|2.3|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.58||||6.58|1.95|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.58||||6.58|1.95|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.58||||6.58||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|8.06||||8.06|3.55|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.06||||8.06|2.39|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|8.06||||8.06|3.79|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.06||||8.06|4.03|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.06||||8.06|4.03|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.06||||8.06|5.08|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.06||||8.06|2.39|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|8.06||||8.06|4.43|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.06||||8.06|5.56|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.06||||8.06|4.03|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.06||||8.06|3.55|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.06||||8.06|2.39|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.06||||8.06|3.55|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.06||||8.06|2.39|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.06||||8.06|2.39|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.06||||8.06|5.56|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.06||||8.06|2.39|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|Self-pay|Self-pay|8.06||||8.06|2.82|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.06||||8.06|2.39|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.06||||8.06|2.39|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.06||||8.06||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|4.41||||4.41|1.94|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.41||||4.41|1.31|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|4.41||||4.41|2.07|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.41||||4.41|2.21|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.41||||4.41|2.21|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.41||||4.41|2.78|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.41||||4.41|1.31|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|4.41||||4.41|2.43|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.41||||4.41|3.04|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.41||||4.41|2.21|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.41||||4.41|1.94|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.41||||4.41|1.31|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.41||||4.41|1.94|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.41||||4.41|1.31|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.41||||4.41|1.31|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.41||||4.41|3.04|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.41||||4.41|1.31|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|Self-pay|Self-pay|4.41||||4.41|1.54|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.41||||4.41|1.31|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.41||||4.41|1.31|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.41||||4.41||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|AARP [1000]|AARP [100000]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|8.68||||8.68|3.83|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.68||||8.68|2.57|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|8.68||||8.68|4.08|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.68||||8.68|4.34|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.68||||8.68|4.34|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.68||||8.68|5.47|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.68||||8.68|2.57|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|8.68||||8.68|4.77|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.68||||8.68|5.99|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.68||||8.68|4.34|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.68||||8.68|3.83|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.68||||8.68|2.57|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.68||||8.68|3.83|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.68||||8.68|2.57|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.68||||8.68|2.57|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.68||||8.68|5.99|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.68||||8.68|2.57|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|Self-pay|Self-pay|8.68||||8.68|3.04|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.68||||8.68|2.57|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.68||||8.68|2.57|5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.68||||8.68||5.99|1.31
4452|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.68||||8.68||5.99|1.31
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|9.3||||9.3|4.1|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.3||||9.3|2.76|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|9.3||||9.3|4.37|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.3||||9.3|4.65|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.3||||9.3|4.65|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.3||||9.3|5.86|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.3||||9.3|2.76|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|9.3||||9.3|5.12|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.3||||9.3|6.42|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.3||||9.3|4.65|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.3||||9.3|4.1|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.3||||9.3|2.76|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.3||||9.3|4.1|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.3||||9.3|2.76|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.3||||9.3|2.76|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.3||||9.3|6.42|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.3||||9.3|2.76|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|Self-pay|Self-pay|9.3||||9.3|3.25|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.3||||9.3|2.76|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.3||||9.3|2.76|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.3||||9.3||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|8.06||||8.06|3.55|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.06||||8.06|2.39|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|8.06||||8.06|3.79|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.06||||8.06|4.03|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.06||||8.06|4.03|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.06||||8.06|5.08|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.06||||8.06|2.39|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|8.06||||8.06|4.43|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.06||||8.06|5.56|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.06||||8.06|4.03|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.06||||8.06|3.55|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.06||||8.06|2.39|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.06||||8.06|3.55|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.06||||8.06|2.39|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.06||||8.06|2.39|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.06||||8.06|5.56|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.06||||8.06|2.39|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|Self-pay|Self-pay|8.06||||8.06|2.82|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.06||||8.06|2.39|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.06||||8.06|2.39|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.06||||8.06||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AARP [1000]|AARP [100000]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|6.51||||6.51|2.87|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.51||||6.51|1.93|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|6.51||||6.51|3.06|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.51||||6.51|3.26|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.51||||6.51|3.26|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.51||||6.51|4.1|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.51||||6.51|1.93|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|6.51||||6.51|3.58|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.51||||6.51|4.49|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.51||||6.51|3.26|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.51||||6.51|2.87|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.51||||6.51|1.93|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.51||||6.51|2.87|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.51||||6.51|1.93|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.51||||6.51|1.93|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.51||||6.51|4.49|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.51||||6.51|1.93|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|Self-pay|Self-pay|6.51||||6.51|2.28|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.51||||6.51|1.93|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.51||||6.51|1.93|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.51||||6.51||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|AARP [1000]|AARP [100000]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|13.89||||13.89|6.13|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.89||||13.89|4.12|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|13.89||||13.89|6.53|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.89||||13.89|6.95|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.89||||13.89|6.95|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.89||||13.89|8.75|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.89||||13.89|4.12|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|13.89||||13.89|7.64|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.89||||13.89|9.58|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.89||||13.89|6.95|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.89||||13.89|6.13|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.89||||13.89|4.12|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.89||||13.89|6.13|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.89||||13.89|4.12|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.89||||13.89|4.12|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.89||||13.89|9.58|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.89||||13.89|4.12|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|Self-pay|Self-pay|13.89||||13.89|4.86|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.89||||13.89|4.12|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.89||||13.89|4.12|9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.89||||13.89||9.58|1.93
4454|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.89||||13.89||9.58|1.93
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|AARP [1000]|AARP [100000]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|AETNA [1015]|AETNA [101529]|21.67||||21.67|9.56|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.67||||21.67|6.43|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BCBS UTHCT [115568]|21.67||||21.67|10.18|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.67||||21.67|10.84|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.67||||21.67|10.84|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.67||||21.67|13.65|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.67||||21.67|6.43|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA GWH [126023]|21.67||||21.67|11.92|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.67||||21.67|14.95|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.67||||21.67|10.84|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.67||||21.67|9.56|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.67||||21.67|6.43|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.67||||21.67|9.56|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.67||||21.67|6.43|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.67||||21.67|6.43|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.67||||21.67|14.95|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.67||||21.67|6.43|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|Self-pay|Self-pay|21.67||||21.67|7.58|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.67||||21.67|6.43|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.67||||21.67|6.43|14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.67||||21.67||14.95|6.43
4457|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.67||||21.67||14.95|6.43
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AARP [1000]|AARP [100000]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AETNA [1015]|AETNA [101529]|17.83||||17.83|7.86|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.83||||17.83|5.29|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BCBS UTHCT [115568]|17.83||||17.83|8.38|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.83||||17.83|8.92|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.83||||17.83|8.92|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.83||||17.83|11.23|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.83||||17.83|5.29|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA GWH [126023]|17.83||||17.83|9.81|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.83||||17.83|12.3|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.83||||17.83|8.92|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.83||||17.83|7.86|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.83||||17.83|5.29|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.83||||17.83|7.86|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.83||||17.83|5.29|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.83||||17.83|5.29|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.83||||17.83|12.3|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.83||||17.83|5.29|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|Self-pay|Self-pay|17.83||||17.83|6.24|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.83||||17.83|5.29|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.83||||17.83|5.29|12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.83||||17.83||12.3|5.29
4459|ERX|0250 - PHARMACY-GENERAL|LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.83||||17.83||12.3|5.29
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|AARP [1000]|AARP [100000]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|AETNA [1015]|AETNA [101529]|339.45||||339.45|149.7|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|339.45||||339.45|100.65|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|BCBS [1155]|BCBS UTHCT [115568]|339.45||||339.45|159.54|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|339.45||||339.45|169.73|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|339.45||||339.45|169.73|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|339.45||||339.45|213.85|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|339.45||||339.45|100.65|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|CIGNA [1260]|CIGNA GWH [126023]|339.45||||339.45|186.7|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|339.45||||339.45|234.22|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|339.45||||339.45|169.73|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|339.45||||339.45|149.7|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|339.45||||339.45|100.65|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|339.45||||339.45|149.7|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|339.45||||339.45|100.65|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|339.45||||339.45|100.65|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|339.45||||339.45|234.22|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|339.45||||339.45|100.65|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|Self-pay|Self-pay|339.45||||339.45|118.81|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|339.45||||339.45|100.65|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|339.45||||339.45|100.65|234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|339.45||||339.45||234.22|100.65
4498|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LINDANE 1 % SHAMPOO|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|339.45||||339.45||234.22|100.65
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.36||||0.36|0.16|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.36||||0.36|0.11|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.36||||0.36|0.17|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.36||||0.36|0.18|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.36||||0.36|0.18|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.36||||0.36|0.23|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.36||||0.36|0.11|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.36||||0.36|0.2|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.36||||0.36|0.25|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.36||||0.36|0.18|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.36||||0.36|0.16|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.36||||0.36|0.11|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.36||||0.36|0.16|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.36||||0.36|0.11|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.36||||0.36|0.11|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.36||||0.36|0.25|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.36||||0.36|0.11|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.36||||0.36|0.13|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.36||||0.36|0.11|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.36||||0.36|0.11|0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.36||||0.36||0.25|0.11
450|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.36||||0.36||0.25|0.11
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.73||||2.73|1.2|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.73||||2.73|0.81|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.73||||2.73|1.28|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.73||||2.73|1.37|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.73||||2.73|1.37|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.73||||2.73|1.72|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.73||||2.73|0.81|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.73||||2.73|1.5|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.73||||2.73|1.88|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.73||||2.73|1.37|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.73||||2.73|1.2|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.73||||2.73|0.81|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.73||||2.73|1.2|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.73||||2.73|0.81|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.73||||2.73|0.81|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.73||||2.73|1.88|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.73||||2.73|0.81|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|Self-pay|Self-pay|2.73||||2.73|0.96|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.73||||2.73|0.81|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.73||||2.73|0.81|1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.73||||2.73||1.88|0.81
4504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIOTHYRONINE 25 MCG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.73||||2.73||1.88|0.81
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|AARP [1000]|AARP [100000]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|AETNA [1015]|AETNA [101529]|322||||322|0|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|322||||322|95.47|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|BCBS [1155]|BCBS UTHCT [115568]|322||||322|151.34|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|322||||322|46.04|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|322||||322|161|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|322||||322|202.86|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|322||||322|95.47|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|CIGNA [1260]|CIGNA GWH [126023]|322||||322|177.1|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|322||||322|222.18|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|322||||322|46.44|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|322||||322|0|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|322||||322|95.47|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|322||||322|0|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|322||||322|95.47|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|322||||322|95.47|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|322||||322|222.18|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|322||||322|95.47|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|Self-pay|Self-pay|322||||322|112.7|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|322||||322|95.47|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|322||||322|95.47|222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|322||||322||222.18|46.04
45093288|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE EVAL IN PERSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|322||||322||222.18|46.04
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|AARP [1000]|AARP [100000]|40||||40|40|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40||||40|34.03|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|AETNA [1015]|AETNA [101529]|40||||40|0|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40||||40|11.86|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40||||40|33.69|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40||||40|33.69|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|BCBS [1155]|BCBS UTHCT [115568]|40||||40|18.8|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40||||40|40|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40||||40|20|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40||||40|25.2|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40||||40|11.86|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40||||40|33.69|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|CIGNA [1260]|CIGNA GWH [126023]|40||||40|22|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|40||||40|27.6|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|40||||40|46.44|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40||||40|36.08|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40||||40|0|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40||||40|11.86|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40||||40|33.69|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40||||40|0|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40||||40|11.86|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|40||||40|11.86|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|40||||40|27.6|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40||||40|11.86|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|Self-pay|Self-pay|40||||40|14|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|40||||40|11.86|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40||||40|11.86|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40||||40|40|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|40||||40|33.69|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|40||||40|33.69|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40||||40|40|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40||||40|33.69|67.38|11.86
45093289|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE INTERROGATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40||||40|67.38|67.38|11.86
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|AARP [1000]|AARP [100000]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|AETNA [1015]|AETNA [101529]|234||||234|234|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|234||||234|51.36|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|BCBS [1155]|BCBS UTHCT [115568]|234||||234|109.98|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|234||||234|75.53|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|234||||234|117|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|234||||234|147.42|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|234||||234|51.36|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|CIGNA [1260]|CIGNA GWH [126023]|234||||234|234|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|GROUP PENSION ADMIN [1450]|GPA [145000]|234||||234|161.46|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|234||||234|90.75|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|234||||234|234|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|234||||234|51.36|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|234||||234|234|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|234||||234|51.36|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|234||||234|51.36|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|PHCS [1780]|PHCS MULTIPLAN [178000]|234||||234|161.46|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|234||||234|51.36|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|Self-pay|Self-pay|234||||234|81.9|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|234||||234|51.36|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|234||||234|51.36|234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|234||||234||234|51.36
45099281|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL I|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|234||||234||234|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|AARP [1000]|AARP [100000]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|AETNA [1015]|AETNA [101529]|415||||415|415|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|415||||415|51.36|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|BCBS [1155]|BCBS UTHCT [115568]|415||||415|195.05|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|415||||415|137.12|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|415||||415|207.5|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|415||||415|261.45|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|415||||415|51.36|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|CIGNA [1260]|CIGNA GWH [126023]|415||||415|415|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|GROUP PENSION ADMIN [1450]|GPA [145000]|415||||415|286.35|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|415||||415|164.49|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|415||||415|415|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|415||||415|51.36|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|415||||415|415|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|415||||415|51.36|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|415||||415|51.36|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|PHCS [1780]|PHCS MULTIPLAN [178000]|415||||415|286.35|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|415||||415|51.36|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|Self-pay|Self-pay|415||||415|145.25|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|415||||415|51.36|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|415||||415|51.36|415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|415||||415||415|51.36
45099282|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL II|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|415||||415||415|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|AARP [1000]|AARP [100000]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|AETNA [1015]|AETNA [101529]|727||||727|727|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|727||||727|51.36|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|BCBS [1155]|BCBS UTHCT [115568]|727||||727|341.69|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|727||||727|241.01|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|727||||727|363.5|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|727||||727|458.01|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|727||||727|51.36|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|CIGNA [1260]|CIGNA GWH [126023]|727||||727|600|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|GROUP PENSION ADMIN [1450]|GPA [145000]|727||||727|501.63|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|727||||727|289.5|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|727||||727|727|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|727||||727|51.36|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|727||||727|727|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|727||||727|51.36|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|727||||727|51.36|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|PHCS [1780]|PHCS MULTIPLAN [178000]|727||||727|501.63|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|727||||727|51.36|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|Self-pay|Self-pay|727||||727|254.45|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|727||||727|51.36|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|727||||727|51.36|727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|727||||727||727|51.36
45099283|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL III|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|727||||727||727|51.36
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AARP [1000]|AARP [100000]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AETNA [1015]|AETNA [101529]|1119||||1119|1119|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1119||||1119|331.78|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS [1155]|BCBS UTHCT [115568]|1119||||1119|525.93|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1119||||1119|391.08|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1119||||1119|559.5|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1119||||1119|704.97|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1119||||1119|331.78|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|CIGNA [1260]|CIGNA GWH [126023]|1119||||1119|600|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1119||||1119|772.11|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1119||||1119|454.68|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1119||||1119|1119|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1119||||1119|331.78|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1119||||1119|1119|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1119||||1119|331.78|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1119||||1119|331.78|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1119||||1119|772.11|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1119||||1119|331.78|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|Self-pay|Self-pay|1119||||1119|391.65|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1119||||1119|331.78|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1119||||1119|331.78|1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1119||||1119||1119|331.78
45099284|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL IV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1119||||1119||1119|331.78
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AARP [1000]|AARP [100000]|1868||||1868|543|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1868||||1868|478.2|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AETNA [1015]|AETNA [101529]|1868||||1868|1868|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1868||||1868|553.86|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1868||||1868|473.47|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1868||||1868|473.47|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS [1155]|BCBS UTHCT [115568]|1868||||1868|877.96|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1868||||1868|572.94|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1868||||1868|934|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1868||||1868|1176.84|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1868||||1868|553.86|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1868||||1868|473.47|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|CIGNA [1260]|CIGNA GWH [126023]|1868||||1868|600|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1868||||1868|1288.92|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1868||||1868|652.65|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1868||||1868|507.08|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1868||||1868|1868|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1868||||1868|553.86|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1868||||1868|473.47|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1868||||1868|1868|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1868||||1868|553.86|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1868||||1868|553.86|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1868||||1868|1288.92|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1868||||1868|553.86|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|Self-pay|Self-pay|1868||||1868|653.8|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1868||||1868|553.86|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1868||||1868|553.86|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1868||||1868|543|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1868||||1868|473.47|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1868||||1868|473.47|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1868||||1868|543|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1868||||1868|473.47|1868|473.47
45099285|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER LEVEL V|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1868||||1868|946.93|1868|473.47
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|AARP [1000]|AARP [100000]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|AETNA [1015]|AETNA [101529]|4242||||4242|1870.72|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4242||||4242|1257.75|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|4242||||4242|1993.74|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4242||||4242|806.99|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4242||||4242|2121|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4242||||4242|2672.46|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4242||||4242|1257.75|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|4242||||4242|600|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4242||||4242|2926.98|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4242||||4242|865.85|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4242||||4242|1870.72|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4242||||4242|1257.75|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4242||||4242|1870.72|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4242||||4242|1257.75|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4242||||4242|1257.75|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4242||||4242|2926.98|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4242||||4242|1257.75|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|Self-pay|Self-pay|4242||||4242|1484.7|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4242||||4242|1257.75|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4242||||4242|1257.75|2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4242||||4242||2926.98|600
45099291|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE 1ST 30-74 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4242||||4242||2926.98|600
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|AARP [1000]|AARP [100000]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|AETNA [1015]|AETNA [101529]|688||||688|303.41|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|688||||688|203.99|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|688||||688|323.36|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|688||||688|124.75|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|688||||688|344|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|688||||688|433.44|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|688||||688|203.99|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|688||||688|600|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|688||||688|474.72|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|688||||688|344|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|688||||688|303.41|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|688||||688|203.99|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|688||||688|303.41|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|688||||688|203.99|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|688||||688|203.99|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|688||||688|474.72|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|688||||688|203.99|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|Self-pay|Self-pay|688||||688|240.8|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|688||||688|203.99|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|688||||688|203.99|600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|688||||688||600|124.75
45099292|EAP|0450 - EMERGENCY ROOM-GENERAL|HC ER CRITICAL CARE ADDL 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|688||||688||600|124.75
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.56||||0.56|0.25|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.56||||0.56|0.17|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.56||||0.56|0.26|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.56||||0.56|0.28|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.56||||0.56|0.28|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.56||||0.56|0.35|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.56||||0.56|0.17|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.56||||0.56|0.31|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.56||||0.56|0.39|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.56||||0.56|0.28|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.56||||0.56|0.25|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.56||||0.56|0.17|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.56||||0.56|0.25|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.56||||0.56|0.17|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.56||||0.56|0.17|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.56||||0.56|0.39|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.56||||0.56|0.17|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.56||||0.56|0.2|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.56||||0.56|0.17|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.56||||0.56|0.17|0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.56||||0.56||0.39|0.17
451|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.56||||0.56||0.39|0.17
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.39||||0.39|0.17|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.39||||0.39|0.12|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.39||||0.39|0.18|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.39||||0.39|0.2|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.39||||0.39|0.2|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.39||||0.39|0.25|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.39||||0.39|0.12|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.39||||0.39|0.21|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.39||||0.39|0.27|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.39||||0.39|0.2|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.39||||0.39|0.17|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.39||||0.39|0.12|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.39||||0.39|0.17|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.39||||0.39|0.12|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.39||||0.39|0.12|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.39||||0.39|0.27|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.39||||0.39|0.12|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.39||||0.39|0.14|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.39||||0.39|0.12|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.39||||0.39|0.12|0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.39||||0.39||0.27|0.12
4526|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LISINOPRIL 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.39||||0.39||0.27|0.12
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.35||||0.35|0.15|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.35||||0.35|0.1|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.35||||0.35|0.16|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.35||||0.35|0.18|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.35||||0.35|0.18|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.35||||0.35|0.22|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.35||||0.35|0.1|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.35||||0.35|0.19|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.35||||0.35|0.24|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.35||||0.35|0.18|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.35||||0.35|0.15|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.35||||0.35|0.1|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.35||||0.35|0.15|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.35||||0.35|0.1|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.35||||0.35|0.1|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.35||||0.35|0.24|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.35||||0.35|0.1|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.35||||0.35|0.12|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.35||||0.35|0.1|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.35||||0.35|0.1|0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.35||||0.35||0.24|0.1
4528|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 150 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.35||||0.35||0.24|0.1
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.53||||0.53|0.23|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.53||||0.53|0.16|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.53||||0.53|0.25|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.53||||0.53|0.27|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.53||||0.53|0.27|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.53||||0.53|0.33|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.53||||0.53|0.16|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.53||||0.53|0.29|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.53||||0.53|0.37|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.53||||0.53|0.27|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.53||||0.53|0.23|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.53||||0.53|0.16|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.53||||0.53|0.23|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.53||||0.53|0.16|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.53||||0.53|0.16|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.53||||0.53|0.37|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.53||||0.53|0.16|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.53||||0.53|0.19|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.53||||0.53|0.16|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.53||||0.53|0.16|0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.53||||0.53||0.37|0.16
4529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LITHIUM CARBONATE 300 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.53||||0.53||0.37|0.16
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|AARP [1000]|AARP [100000]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|AETNA [1015]|AETNA [101529]|10.17||||10.17|4.48|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.17||||10.17|3.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|BCBS [1155]|BCBS UTHCT [115568]|10.17||||10.17|4.78|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.17||||10.17|5.09|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.17||||10.17|5.09|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.17||||10.17|6.41|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.17||||10.17|3.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|CIGNA [1260]|CIGNA GWH [126023]|10.17||||10.17|5.59|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.17||||10.17|7.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.17||||10.17|5.09|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.17||||10.17|4.48|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.17||||10.17|3.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.17||||10.17|4.48|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.17||||10.17|3.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.17||||10.17|3.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.17||||10.17|7.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.17||||10.17|3.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|Self-pay|Self-pay|10.17||||10.17|3.56|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.17||||10.17|3.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.17||||10.17|3.02|7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.17||||10.17||7.02|3.02
454|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION|80 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.17||||10.17||7.02|3.02
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.26||||2.26|1|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.26||||2.26|0.67|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|2.26||||2.26|1.06|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.26||||2.26|1.13|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.26||||2.26|1.13|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.26||||2.26|1.42|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.26||||2.26|0.67|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|2.26||||2.26|1.24|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.26||||2.26|1.56|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.26||||2.26|1.13|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.26||||2.26|1|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.26||||2.26|0.67|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.26||||2.26|1|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.26||||2.26|0.67|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.26||||2.26|0.67|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.26||||2.26|1.56|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.26||||2.26|0.67|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.26||||2.26|0.79|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.26||||2.26|0.67|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.26||||2.26|0.67|1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.26||||2.26||1.56|0.67
4560|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOPERAMIDE 2 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.26||||2.26||1.56|0.67
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.14||||0.14|0.06|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.14||||0.14|0.04|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.14||||0.14|0.07|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.14||||0.14|0.07|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.14||||0.14|0.07|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.14||||0.14|0.09|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.14||||0.14|0.04|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.14||||0.14|0.08|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.14||||0.14|0.1|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.14||||0.14|0.07|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.14||||0.14|0.06|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.14||||0.14|0.04|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.14||||0.14|0.06|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.14||||0.14|0.04|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.14||||0.14|0.04|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.14||||0.14|0.1|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.14||||0.14|0.04|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.14||||0.14|0.05|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.14||||0.14|0.04|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.14||||0.14|0.04|0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.14||||0.14||0.1|0.04
4572|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.14||||0.14||0.1|0.04
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.16||||0.16|0.07|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.16||||0.16|0.05|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.16||||0.16|0.08|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.16||||0.16|0.08|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.16||||0.16|0.08|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.16||||0.16|0.1|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.16||||0.16|0.05|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.16||||0.16|0.09|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.16||||0.16|0.11|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.16||||0.16|0.08|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.16||||0.16|0.07|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.16||||0.16|0.05|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.16||||0.16|0.07|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.16||||0.16|0.05|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.16||||0.16|0.05|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.16||||0.16|0.11|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.16||||0.16|0.05|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.16||||0.16|0.06|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.16||||0.16|0.05|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.16||||0.16|0.05|0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.16||||0.16||0.11|0.05
4573|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LORAZEPAM 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.16||||0.16||0.11|0.05
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.4||||3.4|1.5|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.4||||3.4|1.01|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|3.4||||3.4|1.6|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.4||||3.4|1.7|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.4||||3.4|1.7|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.4||||3.4|2.14|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.4||||3.4|1.01|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|3.4||||3.4|1.87|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.4||||3.4|2.35|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.4||||3.4|1.7|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.4||||3.4|1.5|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.4||||3.4|1.01|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.4||||3.4|1.5|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.4||||3.4|1.01|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.4||||3.4|1.01|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.4||||3.4|2.35|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.4||||3.4|1.01|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|3.4||||3.4|1.19|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.4||||3.4|1.01|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.4||||3.4|1.01|2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.4||||3.4||2.35|1.01
4600|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.4||||3.4||2.35|1.01
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.7||||1.7|0.75|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.7||||1.7|0.5|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.7||||1.7|0.8|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.7||||1.7|0.85|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.7||||1.7|0.85|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.7||||1.7|1.07|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.7||||1.7|0.5|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.7||||1.7|0.94|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.7||||1.7|1.17|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.7||||1.7|0.85|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.7||||1.7|0.75|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.7||||1.7|0.5|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.7||||1.7|0.75|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.7||||1.7|0.5|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.7||||1.7|0.5|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.7||||1.7|1.17|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.7||||1.7|0.5|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.7||||1.7|0.59|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.7||||1.7|0.5|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.7||||1.7|0.5|1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.7||||1.7||1.17|0.5
4601|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.7||||1.7||1.17|0.5
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.52||||4.52|1.99|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.52||||4.52|1.34|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|4.52||||4.52|2.12|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.52||||4.52|2.26|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.52||||4.52|2.26|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.52||||4.52|2.85|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.52||||4.52|1.34|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|4.52||||4.52|2.49|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.52||||4.52|3.12|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.52||||4.52|2.26|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.52||||4.52|1.99|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.52||||4.52|1.34|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.52||||4.52|1.99|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.52||||4.52|1.34|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.52||||4.52|1.34|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.52||||4.52|3.12|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.52||||4.52|1.34|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.52||||4.52|1.58|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.52||||4.52|1.34|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.52||||4.52|1.34|3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.52||||4.52||3.12|1.34
4602|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LOXAPINE SUCCINATE 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.52||||4.52||3.12|1.34
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AARP [1000]|AARP [100000]|474||||474|175|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|474||||474|127.81|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AETNA [1015]|AETNA [101529]|474||||474|209.03|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|474||||474|140.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|474||||474|126.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|474||||474|126.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS [1155]|BCBS UTHCT [115568]|474||||474|222.78|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|474||||474|166.31|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|474||||474|237|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|474||||474|298.62|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|474||||474|140.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|474||||474|126.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|CIGNA [1260]|CIGNA GWH [126023]|474||||474|260.7|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|474||||474|327.06|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|474||||474|174.44|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|474||||474|135.53|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|474||||474|209.03|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|474||||474|140.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|474||||474|126.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|474||||474|209.03|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|474||||474|140.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|474||||474|140.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|474||||474|327.06|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|474||||474|140.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|Self-pay|Self-pay|474||||474|165.9|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|474||||474|140.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|474||||474|140.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|474||||474|175|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|474||||474|126.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|474||||474|126.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|474||||474|175|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|474||||474|126.54|327.06|126.54
46094010|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT SIMPLE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|474||||474|253.09|327.06|126.54
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AARP [1000]|AARP [100000]|709||||709|175|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|709||||709|242.2|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AETNA [1015]|AETNA [101529]|709||||709|312.67|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|709||||709|210.22|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|709||||709|239.8|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|709||||709|239.8|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS [1155]|BCBS UTHCT [115568]|709||||709|333.23|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|709||||709|59.11|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|709||||709|354.5|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|709||||709|446.67|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|709||||709|210.22|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|709||||709|239.8|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|CIGNA [1260]|CIGNA GWH [126023]|709||||709|389.95|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|709||||709|489.21|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|709||||709|330.56|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|709||||709|256.83|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|709||||709|312.67|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|709||||709|210.22|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|709||||709|239.8|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|709||||709|312.67|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|709||||709|210.22|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|709||||709|210.22|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|709||||709|489.21|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|709||||709|210.22|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|Self-pay|Self-pay|709||||709|248.15|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|709||||709|210.22|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|709||||709|210.22|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|709||||709|175|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|709||||709|239.8|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|709||||709|239.8|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|709||||709|175|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|709||||709|239.8|489.21|59.11
46094060|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC SPIROMETRY/PFT PRE & POST BRONCH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|709||||709|479.61|489.21|59.11
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AARP [1000]|AARP [100000]|430||||430|175|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|430||||430|242.2|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AETNA [1015]|AETNA [101529]|430||||430|189.63|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|430||||430|127.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|430||||430|239.8|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|430||||430|239.8|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS [1155]|BCBS UTHCT [115568]|430||||430|202.1|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|430||||430|39.41|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|430||||430|215|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|430||||430|270.9|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|430||||430|127.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|430||||430|239.8|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|CIGNA [1260]|CIGNA GWH [126023]|430||||430|236.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|430||||430|296.7|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|430||||430|330.56|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|430||||430|256.83|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|430||||430|189.63|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|430||||430|127.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|430||||430|239.8|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|430||||430|189.63|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|430||||430|127.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|430||||430|127.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|430||||430|296.7|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|430||||430|127.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|Self-pay|Self-pay|430||||430|150.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|430||||430|127.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|430||||430|127.5|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|430||||430|175|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|430||||430|239.8|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|430||||430|239.8|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|430||||430|175|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|430||||430|239.8|479.61|39.41
46094070|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC BRNCSPSM PROVOCATION EVAL MLT SPMTRY W/ADMN AGT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|430||||430|479.61|479.61|39.41
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|AARP [1000]|AARP [100000]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|AETNA [1015]|AETNA [101529]|288||||288|127.01|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|288||||288|85.39|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|BCBS [1155]|BCBS UTHCT [115568]|288||||288|135.36|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|288||||288|288|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|288||||288|144|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|288||||288|181.44|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|288||||288|85.39|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|CIGNA [1260]|CIGNA GWH [126023]|288||||288|158.4|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|288||||288|198.72|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|288||||288|330.56|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|288||||288|127.01|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|288||||288|85.39|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|288||||288|127.01|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|288||||288|85.39|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|288||||288|85.39|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|288||||288|198.72|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|288||||288|85.39|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|Self-pay|Self-pay|288||||288|100.8|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|288||||288|85.39|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|288||||288|85.39|330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|288||||288||330.56|85.39
46094375|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC RESPIRATORY FLOW VOLUME LOOP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|288||||288||330.56|85.39
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|AARP [1000]|AARP [100000]|825||||825|175|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|825||||825|102.53|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|AETNA [1015]|AETNA [101529]|825||||825|363.83|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|825||||825|244.61|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|825||||825|101.52|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|825||||825|101.52|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|BCBS [1155]|BCBS UTHCT [115568]|825||||825|387.75|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|825||||825|128.15|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|825||||825|412.5|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|825||||825|519.75|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|825||||825|244.61|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|825||||825|101.52|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|CIGNA [1260]|CIGNA GWH [126023]|825||||825|453.75|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|825||||825|569.25|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|825||||825|139.94|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|825||||825|108.73|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|825||||825|363.83|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|825||||825|244.61|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|825||||825|101.52|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|825||||825|363.83|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|825||||825|244.61|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|825||||825|244.61|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|825||||825|569.25|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|825||||825|244.61|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|Self-pay|Self-pay|825||||825|288.75|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|825||||825|244.61|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|825||||825|244.61|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|825||||825|175|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|825||||825|101.52|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|825||||825|101.52|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|825||||825|175|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|825||||825|101.52|569.25|101.52
46094618|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TESTING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|825||||825|203.04|569.25|101.52
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|AARP [1000]|AARP [100000]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|AETNA [1015]|AETNA [101529]|468||||468|206.39|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|468||||468|138.76|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|BCBS [1155]|BCBS UTHCT [115568]|468||||468|219.96|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|468||||468|119.1|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|468||||468|234|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|468||||468|294.84|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|468||||468|138.76|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|CIGNA [1260]|CIGNA GWH [126023]|468||||468|257.4|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|468||||468|322.92|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|468||||468|330.56|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|468||||468|206.39|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|468||||468|138.76|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|468||||468|206.39|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|468||||468|138.76|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|468||||468|138.76|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|468||||468|322.92|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|468||||468|138.76|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|Self-pay|Self-pay|468||||468|163.8|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|468||||468|138.76|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|468||||468|138.76|330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|468||||468||330.56|119.1
46094621|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY STRESS TEST COMPLEX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|468||||468||330.56|119.1
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|AARP [1000]|AARP [100000]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|AETNA [1015]|AETNA [101529]|244||||244|107.6|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244||||244|72.35|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|BCBS [1155]|BCBS UTHCT [115568]|244||||244|114.68|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244||||244|166.31|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244||||244|122|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244||||244|153.72|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244||||244|72.35|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|CIGNA [1260]|CIGNA GWH [126023]|244||||244|134.2|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|244||||244|168.36|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|244||||244|174.44|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244||||244|107.6|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244||||244|72.35|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244||||244|107.6|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244||||244|72.35|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|244||||244|72.35|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|244||||244|168.36|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244||||244|72.35|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|Self-pay|Self-pay|244||||244|85.4|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|244||||244|72.35|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244||||244|72.35|174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244||||244||174.44|72.35
46094680|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC O2 UPTAKE EXPIRD GAS REST/EXERCIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244||||244||174.44|72.35
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|AARP [1000]|AARP [100000]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|AETNA [1015]|AETNA [101529]|275||||275|121.28|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|275||||275|81.54|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|BCBS [1155]|BCBS UTHCT [115568]|275||||275|129.25|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|275||||275|38.8|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|275||||275|137.5|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|275||||275|173.25|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|275||||275|81.54|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|CIGNA [1260]|CIGNA GWH [126023]|275||||275|151.25|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|275||||275|189.75|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|275||||275|69.58|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|275||||275|121.28|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|275||||275|81.54|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|275||||275|121.28|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|275||||275|81.54|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|275||||275|81.54|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|275||||275|189.75|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|275||||275|81.54|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|Self-pay|Self-pay|275||||275|96.25|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|275||||275|81.54|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|275||||275|81.54|189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|275||||275||189.75|38.8
46094690|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC INDIRECT CALORIMETRY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|275||||275||189.75|38.8
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|AARP [1000]|AARP [100000]|235||||235|175|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|235||||235|242.2|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|AETNA [1015]|AETNA [101529]|235||||235|103.64|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|235||||235|69.68|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|235||||235|239.8|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|235||||235|239.8|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|BCBS [1155]|BCBS UTHCT [115568]|235||||235|110.45|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|235||||235|235|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|235||||235|117.5|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|235||||235|148.05|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|235||||235|69.68|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|235||||235|239.8|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|CIGNA [1260]|CIGNA GWH [126023]|235||||235|129.25|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|235||||235|162.15|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|235||||235|330.56|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|235||||235|256.83|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|235||||235|103.64|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|235||||235|69.68|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|235||||235|239.8|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|235||||235|103.64|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|235||||235|69.68|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|235||||235|69.68|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|235||||235|162.15|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|235||||235|69.68|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|Self-pay|Self-pay|235||||235|82.25|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|235||||235|69.68|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|235||||235|69.68|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|235||||235|175|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|235||||235|239.8|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|235||||235|239.8|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|235||||235|175|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|235||||235|239.8|479.61|69.68
46094726|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PLETHYSMOG LUNG VOL W/ OR W/O AIRWAY RESIST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|235||||235|479.61|479.61|69.68
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|AARP [1000]|AARP [100000]|476||||476|175|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|476||||476|127.81|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|AETNA [1015]|AETNA [101529]|476||||476|209.92|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|476||||476|141.13|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|476||||476|126.54|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|476||||476|126.54|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|BCBS [1155]|BCBS UTHCT [115568]|476||||476|223.72|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|476||||476|166.31|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|476||||476|238|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|476||||476|299.88|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|476||||476|141.13|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|476||||476|126.54|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|CIGNA [1260]|CIGNA GWH [126023]|476||||476|261.8|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|476||||476|328.44|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|476||||476|174.44|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|476||||476|135.53|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|476||||476|209.92|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|476||||476|141.13|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|476||||476|126.54|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|476||||476|209.92|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|476||||476|141.13|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|476||||476|141.13|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|476||||476|328.44|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|476||||476|141.13|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|Self-pay|Self-pay|476||||476|166.6|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|476||||476|141.13|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|476||||476|141.13|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|476||||476|175|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|476||||476|126.54|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|476||||476|126.54|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|476||||476|175|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|476||||476|126.54|328.44|126.54
46094727|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULM FUNCTION LUNG VOLUME BY GAS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|476||||476|253.09|328.44|126.54
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|AARP [1000]|AARP [100000]|282||||282|175|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|282||||282||194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|AETNA [1015]|AETNA [101529]|282||||282|124.36|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|282||||282|83.61|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|282||||282||194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|282||||282||194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|BCBS [1155]|BCBS UTHCT [115568]|282||||282|132.54|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|282||||282|56.49|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|282||||282|141|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|282||||282|177.66|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|282||||282|83.61|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|282||||282||194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|CIGNA [1260]|CIGNA GWH [126023]|282||||282|155.1|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|GROUP PENSION ADMIN [1450]|GPA [145000]|282||||282|194.58|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|282||||282|141|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|282||||282||194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|282||||282|124.36|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|282||||282|83.61|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|282||||282||194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|282||||282|124.36|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|282||||282|83.61|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|282||||282|83.61|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|PHCS [1780]|PHCS MULTIPLAN [178000]|282||||282|194.58|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|282||||282|83.61|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|Self-pay|Self-pay|282||||282|98.7|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|282||||282|83.61|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|282||||282|83.61|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|282||||282|175|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|282||||282||194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|282||||282||194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|282||||282|175|194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|282||||282||194.58|56.49
46094729|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC CARBON MONOXIDE DIFF (DLCO)|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|282||||282||194.58|56.49
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AARP [1000]|AARP [100000]|193||||193|175|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193||||193||175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AETNA [1015]|AETNA [101529]|193||||193|85.11|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193||||193|57.22|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193||||193||175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193||||193||175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BCBS UTHCT [115568]|193||||193|90.71|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193||||193|3.5|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193||||193|96.5|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193||||193|121.59|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193||||193|57.22|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193||||193||175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|CIGNA [1260]|CIGNA GWH [126023]|193||||193|106.15|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|193||||193|133.17|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|193||||193|96.5|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193||||193||175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193||||193|85.11|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193||||193|57.22|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193||||193||175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193||||193|85.11|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193||||193|57.22|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|193||||193|57.22|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|193||||193|133.17|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193||||193|57.22|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|Self-pay|Self-pay|193||||193|67.55|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|193||||193|57.22|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193||||193|57.22|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193||||193|175|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|193||||193||175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|193||||193||175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193||||193|175|175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193||||193||175|3.5
46094760|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY SINGLE DETERMINATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193||||193||175|3.5
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AARP [1000]|AARP [100000]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AETNA [1015]|AETNA [101529]|193||||193|85.11|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193||||193|57.22|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BCBS UTHCT [115568]|193||||193|90.71|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193||||193|5.7|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193||||193|96.5|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193||||193|121.59|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193||||193|57.22|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|CIGNA [1260]|CIGNA GWH [126023]|193||||193|106.15|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|193||||193|133.17|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|193||||193|96.5|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193||||193|85.11|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193||||193|57.22|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193||||193|85.11|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193||||193|57.22|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|193||||193|57.22|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|193||||193|133.17|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193||||193|57.22|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|Self-pay|Self-pay|193||||193|67.55|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|193||||193|57.22|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193||||193|57.22|133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193||||193||133.17|5.7
46094761|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY MULTI DETERMINATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193||||193||133.17|5.7
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AARP [1000]|AARP [100000]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AETNA [1015]|AETNA [101529]|1044||||1044|460.4|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1044||||1044|309.55|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BCBS UTHCT [115568]|1044||||1044|490.68|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1044||||1044|166.31|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1044||||1044|522|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1044||||1044|657.72|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1044||||1044|309.55|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|CIGNA [1260]|CIGNA GWH [126023]|1044||||1044|574.2|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1044||||1044|720.36|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1044||||1044|174.44|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1044||||1044|460.4|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1044||||1044|309.55|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1044||||1044|460.4|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1044||||1044|309.55|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1044||||1044|309.55|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1044||||1044|720.36|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1044||||1044|309.55|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|Self-pay|Self-pay|1044||||1044|365.4|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1044||||1044|309.55|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1044||||1044|309.55|720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1044||||1044||720.36|166.31
46094762|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULSE OXIMETRY OVERNIGHT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1044||||1044||720.36|166.31
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AARP [1000]|AARP [100000]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AETNA [1015]|AETNA [101529]|193||||193|85.11|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|193||||193|57.22|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BCBS UTHCT [115568]|193||||193|90.71|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|193||||193|166.31|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|193||||193|96.5|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|193||||193|121.59|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|193||||193|57.22|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|CIGNA [1260]|CIGNA GWH [126023]|193||||193|106.15|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|193||||193|133.17|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|193||||193|174.44|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|193||||193|85.11|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|193||||193|57.22|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|193||||193|85.11|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|193||||193|57.22|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|193||||193|57.22|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|193||||193|133.17|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|193||||193|57.22|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|Self-pay|Self-pay|193||||193|67.55|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|193||||193|57.22|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|193||||193|57.22|174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|193||||193||174.44|57.22
46094799|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC PULMONARY PROC UNLISTED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|193||||193||174.44|57.22
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|AARP [1000]|AARP [100000]|163||||163|163|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|163||||163|30.99|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|AETNA [1015]|AETNA [101529]|163||||163|71.88|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|163||||163|48.33|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|163||||163|30.69|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|163||||163|30.69|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|BCBS [1155]|BCBS UTHCT [115568]|163||||163|76.61|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|163||||163|38.8|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|163||||163|81.5|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|163||||163|102.69|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|163||||163|48.33|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|163||||163|30.69|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|CIGNA [1260]|CIGNA GWH [126023]|163||||163|89.65|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|163||||163|112.47|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|163||||163|42.3|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|163||||163|32.86|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|163||||163|71.88|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|163||||163|48.33|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|163||||163|30.69|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|163||||163|71.88|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|163||||163|48.33|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|163||||163|48.33|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|163||||163|112.47|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|163||||163|48.33|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|Self-pay|Self-pay|163||||163|57.05|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|163||||163|48.33|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|163||||163|48.33|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|163||||163|163|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|163||||163|30.69|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|163||||163|30.69|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|163||||163|163|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|163||||163|30.69|163|30.69
46095012|EAP|0460 - PULMONARY FUNCTION-GENERAL|HC NITRIC OXIDE EXPIRED GAS DETERMINATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|163||||163|61.37|163|30.69
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AARP [1000]|AARP [100000]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AETNA [1015]|AETNA [101529]|135.47||||135.47|93.65|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135.47||||135.47|40.17|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BCBS UTHCT [115568]|135.47||||135.47|63.67|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135.47||||135.47|0|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135.47||||135.47|67.74|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135.47||||135.47|85.35|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135.47||||135.47|40.17|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|CIGNA [1260]|CIGNA GWH [126023]|135.47||||135.47|74.51|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|135.47||||135.47|93.47|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|135.47||||135.47|48.64|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135.47||||135.47|93.65|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135.47||||135.47|40.17|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135.47||||135.47|93.65|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135.47||||135.47|40.17|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|135.47||||135.47|40.17|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|135.47||||135.47|93.47|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135.47||||135.47|40.17|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|Self-pay|Self-pay|135.47||||135.47|47.41|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|135.47||||135.47|40.17|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135.47||||135.47|40.17|93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135.47||||135.47||93.65|40.17
464|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPHOTERICIN B 50 MG SOLUTION FOR INJECTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135.47||||135.47||93.65|40.17
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|15.5||||15.5|4.46|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|1.11|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|4.46|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|4.46|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|1.11
469|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 1 GRAM SOLUTION FOR INJECTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|1.11
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|AARP [1000]|AARP [100000]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|AETNA [1015]|AETNA [101529]|524||||524|231.08|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|524||||524|155.37|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|BCBS [1155]|BCBS UTHCT [115568]|524||||524|246.28|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|524||||524|46.85|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|524||||524|262|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|524||||524|330.12|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|524||||524|155.37|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|CIGNA [1260]|CIGNA GWH [126023]|524||||524|288.2|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|524||||524|361.56|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|524||||524|205.49|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|524||||524|231.08|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|524||||524|155.37|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|524||||524|231.08|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|524||||524|155.37|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|524||||524|155.37|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|524||||524|361.56|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|524||||524|155.37|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|Self-pay|Self-pay|524||||524|183.4|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|524||||524|155.37|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|524||||524|155.37|361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|524||||524||361.56|46.85
47192511|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC NASOPHARYNGOSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|524||||524||361.56|46.85
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|AARP [1000]|AARP [100000]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|AETNA [1015]|AETNA [101529]|95||||95|41.9|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|95||||95|28.17|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|BCBS [1155]|BCBS UTHCT [115568]|95||||95|44.65|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|95||||95|38.8|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|95||||95|47.5|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|95||||95|59.85|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|95||||95|28.17|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|CIGNA [1260]|CIGNA GWH [126023]|95||||95|52.25|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|95||||95|65.55|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|95||||95|42.3|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|95||||95|41.9|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|95||||95|28.17|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|95||||95|41.9|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|95||||95|28.17|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|95||||95|28.17|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|95||||95|65.55|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|95||||95|28.17|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|Self-pay|Self-pay|95||||95|33.25|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|95||||95|28.17|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|95||||95|28.17|65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|95||||95||65.55|28.17
47192567|EAP|0471 - AUDIOLOGY-DIAGNOSTIC|HC TYMPANOMETRY IMPEDANCE TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|95||||95||65.55|28.17
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|22.05||||22.05|8.93|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.05||||22.05|6.54|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BCBS UTHCT [115568]|22.05||||22.05|10.36|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.05||||22.05|0|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.05||||22.05|11.03|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.05||||22.05|13.89|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.05||||22.05|6.54|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA GWH [126023]|22.05||||22.05|12.13|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|22.05||||22.05|15.21|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22.05||||22.05|1.11|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.05||||22.05|8.93|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.05||||22.05|6.54|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.05||||22.05|8.93|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.05||||22.05|6.54|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|22.05||||22.05|6.54|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|22.05||||22.05|15.21|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.05||||22.05|6.54|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|22.05||||22.05|7.72|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22.05||||22.05|6.54|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.05||||22.05|6.54|15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.05||||22.05||15.21|1.11
472|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.05||||22.05||15.21|1.11
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|AARP [1000]|AARP [100000]|7.52||||7.52|3.58|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.52||||7.52||5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|AETNA [1015]|AETNA [101529]|7.52||||7.52|4.66|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.52||||7.52|2.23|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.52||||7.52||5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.52||||7.52||5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BCBS UTHCT [115568]|7.52||||7.52|3.53|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.52||||7.52|0|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.52||||7.52|3.76|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.52||||7.52|4.74|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.52||||7.52|2.23|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.52||||7.52||5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|CIGNA [1260]|CIGNA GWH [126023]|7.52||||7.52|4.14|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.52||||7.52|5.19|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.52||||7.52|2.98|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.52||||7.52||5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.52||||7.52|4.66|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.52||||7.52|2.23|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.52||||7.52||5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.52||||7.52|4.66|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.52||||7.52|2.23|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.52||||7.52|2.23|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.52||||7.52|5.19|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.52||||7.52|2.23|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|Self-pay|Self-pay|7.52||||7.52|2.63|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.52||||7.52|2.23|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.52||||7.52|2.23|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.52||||7.52|3.58|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.52||||7.52||5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.52||||7.52||5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.52||||7.52|3.58|5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.52||||7.52||5.19|2.23
4750|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MANNITOL 25 % INTRAVENOUS SOLUTION|25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.52||||7.52||5.19|2.23
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|AARP [1000]|AARP [100000]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|AETNA [1015]|AETNA [101529]|1397||||1397|0|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1397||||1397|414.21|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|BCBS [1155]|BCBS UTHCT [115568]|1397||||1397|656.59|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1397||||1397|698.5|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1397||||1397|880.11|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1397||||1397|414.21|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|CIGNA [1260]|CIGNA GWH [126023]|1397||||1397|768.35|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1397||||1397|963.93|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1397||||1397|702.39|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1397||||1397|0|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1397||||1397|414.21|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1397||||1397|0|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1397||||1397|414.21|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1397||||1397|414.21|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1397||||1397|963.93|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1397||||1397|414.21|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|Self-pay|Self-pay|1397||||1397|488.95|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1397||||1397|414.21|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1397||||1397|414.21|963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1397||||1397||963.93|414.21
48092960|EAP|0480 - CARDIOLOGY-GENERAL|HC CARDIOVERSION ELECTIVE EXTERNAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1397||||1397||963.93|414.21
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|AARP [1000]|AARP [100000]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|AETNA [1015]|AETNA [101529]|137||||137|0|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|137||||137|40.62|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|BCBS [1155]|BCBS UTHCT [115568]|137||||137|64.39|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|137||||137|46.04|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|137||||137|68.5|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|137||||137|86.31|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|137||||137|40.62|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|CIGNA [1260]|CIGNA GWH [126023]|137||||137|75.35|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|137||||137|94.53|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|137||||137|46.44|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|137||||137|0|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|137||||137|40.62|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|137||||137|0|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|137||||137|40.62|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|137||||137|40.62|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|137||||137|94.53|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|137||||137|40.62|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|Self-pay|Self-pay|137||||137|47.95|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|137||||137|40.62|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|137||||137|40.62|94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|137||||137||94.53|40.62
48093260|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL IMPLANTABLE SUBQ LEAD DFB SYSTEM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|137||||137||94.53|40.62
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|AARP [1000]|AARP [100000]|67||||67|67|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|67||||67|34.03|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|AETNA [1015]|AETNA [101529]|67||||67|0|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|67||||67|19.87|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|67||||67|33.69|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|67||||67|33.69|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|BCBS [1155]|BCBS UTHCT [115568]|67||||67|31.49|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|67||||67|46.04|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|67||||67|33.5|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|67||||67|42.21|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|67||||67|19.87|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|67||||67|33.69|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|CIGNA [1260]|CIGNA GWH [126023]|67||||67|36.85|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|67||||67|46.23|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|67||||67|46.44|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|67||||67|36.08|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|67||||67|0|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|67||||67|19.87|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|67||||67|33.69|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|67||||67|0|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|67||||67|19.87|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|67||||67|19.87|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|67||||67|46.23|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|67||||67|19.87|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|Self-pay|Self-pay|67||||67|23.45|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|67||||67|19.87|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|67||||67|19.87|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|67||||67|67|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|67||||67|33.69|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|67||||67|33.69|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|67||||67|67|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|67||||67|33.69|67.38|19.87
48093279|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL SNGL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|67||||67|67.38|67.38|19.87
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|AARP [1000]|AARP [100000]|322||||322|322|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|322||||322|34.03|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|AETNA [1015]|AETNA [101529]|322||||322|0|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|322||||322|95.47|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|322||||322|33.69|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|322||||322|33.69|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|BCBS [1155]|BCBS UTHCT [115568]|322||||322|151.34|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|322||||322|46.04|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|322||||322|161|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|322||||322|202.86|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|322||||322|95.47|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|322||||322|33.69|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|CIGNA [1260]|CIGNA GWH [126023]|322||||322|177.1|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|322||||322|222.18|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|322||||322|46.44|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|322||||322|36.08|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|322||||322|0|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|322||||322|95.47|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|322||||322|33.69|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|322||||322|0|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|322||||322|95.47|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|322||||322|95.47|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|322||||322|222.18|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|322||||322|95.47|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|Self-pay|Self-pay|322||||322|112.7|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|322||||322|95.47|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|322||||322|95.47|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|322||||322|322|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|322||||322|33.69|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|322||||322|33.69|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|322||||322|322|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|322||||322|33.69|322|33.69
48093280|EAP|0480 - CARDIOLOGY-GENERAL|HC PM DEVICE PROGR EVAL DUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|322||||322|67.38|322|33.69
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|AARP [1000]|AARP [100000]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|AETNA [1015]|AETNA [101529]|63||||63|0|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63||||63|18.68|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|BCBS [1155]|BCBS UTHCT [115568]|63||||63|29.61|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63||||63|46.04|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63||||63|31.5|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63||||63|39.69|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63||||63|18.68|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|CIGNA [1260]|CIGNA GWH [126023]|63||||63|34.65|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63||||63|43.47|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63||||63|46.44|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63||||63|0|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63||||63|18.68|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63||||63|0|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63||||63|18.68|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63||||63|18.68|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63||||63|43.47|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63||||63|18.68|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|Self-pay|Self-pay|63||||63|22.05|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63||||63|18.68|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63||||63|18.68|46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63||||63||46.44|18.68
48093281|EAP|0480 - CARDIOLOGY-GENERAL|HC PROGRAM EVAL IMPLANTABLE IN PRSN MULTI LD PACER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63||||63||46.44|18.68
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|AARP [1000]|AARP [100000]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|AETNA [1015]|AETNA [101529]|40||||40|0|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40||||40|11.86|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|BCBS [1155]|BCBS UTHCT [115568]|40||||40|18.8|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40||||40|40|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40||||40|20|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40||||40|25.2|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40||||40|11.86|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|CIGNA [1260]|CIGNA GWH [126023]|40||||40|22|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|40||||40|27.6|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|40||||40|46.44|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40||||40|0|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40||||40|11.86|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40||||40|0|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40||||40|11.86|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|40||||40|11.86|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|40||||40|27.6|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40||||40|11.86|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|Self-pay|Self-pay|40||||40|14|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|40||||40|11.86|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40||||40|11.86|46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40||||40||46.44|11.86
48093282|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMNG DEV EVAL IMPLANTABLE IN PERSN 1 LD DFB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|AARP [1000]|AARP [100000]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|AETNA [1015]|AETNA [101529]|40||||40|0|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|40||||40|11.86|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|BCBS [1155]|BCBS UTHCT [115568]|40||||40|18.8|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|40||||40|40|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|40||||40|20|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|40||||40|25.2|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|40||||40|11.86|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|CIGNA [1260]|CIGNA GWH [126023]|40||||40|22|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|GROUP PENSION ADMIN [1450]|GPA [145000]|40||||40|27.6|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|40||||40|46.44|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|40||||40|0|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|40||||40|11.86|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|40||||40|0|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|40||||40|11.86|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|40||||40|11.86|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|PHCS [1780]|PHCS MULTIPLAN [178000]|40||||40|27.6|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|40||||40|11.86|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|Self-pay|Self-pay|40||||40|14|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|40||||40|11.86|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|40||||40|11.86|46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|40||||40||46.44|11.86
48093283|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG EVAL IMPLANTABLE IN PRSN DUAL LEAD DFB|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|40||||40||46.44|11.86
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|AARP [1000]|AARP [100000]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|AETNA [1015]|AETNA [101529]|202||||202|0|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|202||||202|59.89|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|BCBS [1155]|BCBS UTHCT [115568]|202||||202|94.94|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|202||||202|46.04|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|202||||202|101|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|202||||202|127.26|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|202||||202|59.89|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|CIGNA [1260]|CIGNA GWH [126023]|202||||202|111.1|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|202||||202|139.38|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|202||||202|46.44|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|202||||202|0|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|202||||202|59.89|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|202||||202|0|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|202||||202|59.89|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|202||||202|59.89|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|202||||202|139.38|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|202||||202|59.89|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|Self-pay|Self-pay|202||||202|70.7|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|202||||202|59.89|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|202||||202|59.89|139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|202||||202||139.38|46.04
48093284|EAP|0480 - CARDIOLOGY-GENERAL|HC ICD DEVICE PROGER EVAL MULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|202||||202||139.38|46.04
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|AARP [1000]|AARP [100000]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|AETNA [1015]|AETNA [101529]|63||||63|0|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63||||63|18.68|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|BCBS [1155]|BCBS UTHCT [115568]|63||||63|29.61|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63||||63|46.04|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63||||63|31.5|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63||||63|39.69|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63||||63|18.68|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|CIGNA [1260]|CIGNA GWH [126023]|63||||63|34.65|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63||||63|43.47|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63||||63|46.44|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63||||63|0|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63||||63|18.68|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63||||63|0|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63||||63|18.68|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63||||63|18.68|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63||||63|43.47|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63||||63|18.68|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|Self-pay|Self-pay|63||||63|22.05|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63||||63|18.68|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63||||63|18.68|46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63||||63||46.44|18.68
48093285|EAP|0480 - CARDIOLOGY-GENERAL|HC PRGRMG DEV EVAL SCRMS PHYS/QHP IN PERSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63||||63||46.44|18.68
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|AARP [1000]|AARP [100000]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|AETNA [1015]|AETNA [101529]|34||||34|0|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|34||||34|10.08|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|BCBS [1155]|BCBS UTHCT [115568]|34||||34|15.98|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|34||||34|34|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|34||||34|17|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|34||||34|21.42|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|34||||34|10.08|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|CIGNA [1260]|CIGNA GWH [126023]|34||||34|18.7|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|34||||34|23.46|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|34||||34|46.44|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|34||||34|0|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|34||||34|10.08|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|34||||34|0|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|34||||34|10.08|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|34||||34|10.08|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|34||||34|23.46|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|34||||34|10.08|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|Self-pay|Self-pay|34||||34|11.9|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|34||||34|10.08|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|34||||34|10.08|46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|34||||34||46.44|10.08
48093290|EAP|0480 - CARDIOLOGY-GENERAL|HC ICM DEVICE EVAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|34||||34||46.44|10.08
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|AARP [1000]|AARP [100000]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|AETNA [1015]|AETNA [101529]|63||||63|0|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63||||63|18.68|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|BCBS [1155]|BCBS UTHCT [115568]|63||||63|29.61|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63||||63|21.31|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63||||63|31.5|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63||||63|39.69|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63||||63|18.68|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|CIGNA [1260]|CIGNA GWH [126023]|63||||63|34.65|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63||||63|43.47|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63||||63|30.84|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63||||63|0|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63||||63|18.68|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63||||63|0|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63||||63|18.68|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63||||63|18.68|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63||||63|43.47|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63||||63|18.68|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|Self-pay|Self-pay|63||||63|22.05|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63||||63|18.68|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63||||63|18.68|43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63||||63||43.47|18.68
48093291|EAP|0480 - CARDIOLOGY-GENERAL|HC ILR DEVICE INTERROGATE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63||||63||43.47|18.68
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|AARP [1000]|AARP [100000]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|AETNA [1015]|AETNA [101529]|1878||||1878|0|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1878||||1878|222.2|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|BCBS [1155]|BCBS UTHCT [115568]|1878||||1878|882.66|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1878||||1878|220.67|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1878||||1878|939|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1878||||1878|1183.14|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1878||||1878|222.2|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|CIGNA [1260]|CIGNA GWH [126023]|1878||||1878|1032.9|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1878||||1878|1295.82|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1878||||1878|603.61|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1878||||1878|0|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1878||||1878|222.2|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1878||||1878|0|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1878||||1878|222.2|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1878||||1878|222.2|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1878||||1878|1295.82|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1878||||1878|222.2|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|Self-pay|Self-pay|1878||||1878|657.3|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1878||||1878|222.2|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1878||||1878|222.2|1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1878||||1878||1295.82|220.67
48093303|EAP|0480 - CARDIOLOGY-GENERAL|HC ECHO COMPLETE CONG CARD ANOMOLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1878||||1878||1295.82|220.67
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AARP [1000]|AARP [100000]|1303||||1303|375|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1303||||1303|242.2|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AETNA [1015]|AETNA [101529]|1303||||1303|56.86|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1303||||1303|386.34|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1303||||1303|239.8|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1303||||1303|239.8|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS [1155]|BCBS UTHCT [115568]|1303||||1303|612.41|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1303||||1303|303.57|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1303||||1303|651.5|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1303||||1303|820.89|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1303||||1303|386.34|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1303||||1303|239.8|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|CIGNA [1260]|CIGNA GWH [126023]|1303||||1303|716.65|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1303||||1303|899.07|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1303||||1303|330.56|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1303||||1303|256.83|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1303||||1303|56.86|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1303||||1303|386.34|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1303||||1303|239.8|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1303||||1303|56.86|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1303||||1303|386.34|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1303||||1303|386.34|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1303||||1303|899.07|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1303||||1303|386.34|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|Self-pay|Self-pay|1303||||1303|456.05|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1303||||1303|386.34|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1303||||1303|386.34|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1303||||1303|375|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1303||||1303|239.8|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1303||||1303|239.8|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1303||||1303|375|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1303||||1303|239.8|899.07|56.86
48293017|EAP|0482 - CARDIOLOGY-STRESS TEST|HC STRESS TEST TRACING ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1303||||1303|479.61|899.07|56.86
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|AARP [1000]|AARP [100000]|1583||||1583|350|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1583||||1583|655.02|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|AETNA [1015]|AETNA [101529]|1583||||1583|698.1|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1583||||1583|469.36|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1583||||1583|648.54|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1583||||1583|648.54|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|BCBS [1155]|BCBS UTHCT [115568]|1583||||1583|744.01|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1583||||1583|831.89|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1583||||1583|791.5|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1583||||1583|997.29|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1583||||1583|469.36|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1583||||1583|648.54|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|CIGNA [1260]|CIGNA GWH [126023]|1583||||1583|870.65|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1583||||1583|1092.27|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1583||||1583|893.98|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1583||||1583|694.58|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1583||||1583|698.1|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1583||||1583|469.36|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1583||||1583|648.54|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1583||||1583|698.1|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1583||||1583|469.36|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1583||||1583|469.36|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1583||||1583|1092.27|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1583||||1583|469.36|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|Self-pay|Self-pay|1583||||1583|554.05|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1583||||1583|469.36|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1583||||1583|469.36|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1583||||1583|350|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1583||||1583|648.54|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1583||||1583|648.54|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1583||||1583|350|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1583||||1583|648.54|1297.07|350
48308929|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC TTE W OR W/WO CONTRAST COMP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1583||||1583|1297.07|1297.07|350
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|AARP [1000]|AARP [100000]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|AETNA [1015]|AETNA [101529]|2070||||2070|912.87|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2070||||2070|613.76|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|BCBS [1155]|BCBS UTHCT [115568]|2070||||2070|972.9|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2070||||2070|831.89|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2070||||2070|1035|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2070||||2070|1304.1|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2070||||2070|613.76|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|CIGNA [1260]|CIGNA GWH [126023]|2070||||2070|1138.5|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2070||||2070|1428.3|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2070||||2070|893.98|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2070||||2070|912.87|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2070||||2070|613.76|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2070||||2070|912.87|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2070||||2070|613.76|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2070||||2070|613.76|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2070||||2070|1428.3|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2070||||2070|613.76|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|Self-pay|Self-pay|2070||||2070|724.5|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2070||||2070|613.76|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2070||||2070|613.76|1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2070||||2070||1428.3|613.76
48308930|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST&STRESS CONT ECG&CONTRST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2070||||2070||1428.3|613.76
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AARP [1000]|AARP [100000]|1421||||1421|350|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1421||||1421|442.27|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AETNA [1015]|AETNA [101529]|1421||||1421|350.38|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1421||||1421|421.33|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1421||||1421|437.89|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1421||||1421|437.89|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|1421||||1421|667.87|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1421||||1421|169.01|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1421||||1421|710.5|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1421||||1421|895.23|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1421||||1421|421.33|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1421||||1421|437.89|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|1421||||1421|781.55|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1421||||1421|980.49|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1421||||1421|603.61|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1421||||1421|468.98|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1421||||1421|350.38|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1421||||1421|421.33|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1421||||1421|437.89|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1421||||1421|350.38|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1421||||1421|421.33|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1421||||1421|421.33|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1421||||1421|980.49|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1421||||1421|421.33|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|Self-pay|Self-pay|1421||||1421|497.35|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1421||||1421|421.33|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1421||||1421|421.33|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1421||||1421|350|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1421||||1421|437.89|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1421||||1421|437.89|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1421||||1421|350|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1421||||1421|437.89|980.49|169.01
48393306|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/ DOPPLER COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1421||||1421|875.79|980.49|169.01
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|AARP [1000]|AARP [100000]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|AETNA [1015]|AETNA [101529]|1246||||1246|238.54|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1246||||1246|132.65|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|BCBS [1155]|BCBS UTHCT [115568]|1246||||1246|585.62|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1246||||1246|120.84|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1246||||1246|623|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1246||||1246|784.98|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1246||||1246|132.65|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|CIGNA [1260]|CIGNA GWH [126023]|1246||||1246|685.3|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1246||||1246|859.74|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1246||||1246|287.66|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1246||||1246|238.54|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1246||||1246|132.65|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1246||||1246|238.54|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1246||||1246|132.65|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1246||||1246|132.65|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1246||||1246|859.74|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1246||||1246|132.65|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|Self-pay|Self-pay|1246||||1246|436.1|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1246||||1246|132.65|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1246||||1246|132.65|859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1246||||1246||859.74|120.84
48393307|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W/O DOPPLER - M-MODE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1246||||1246||859.74|120.84
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AARP [1000]|AARP [100000]|1332||||1332|350|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1332||||1332|210.77|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AETNA [1015]|AETNA [101529]|1332||||1332|166.92|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1332||||1332|92.89|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1332||||1332|208.68|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1332||||1332|208.68|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|1332||||1332|626.04|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1332||||1332|99.39|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1332||||1332|666|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1332||||1332|839.16|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1332||||1332|92.89|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1332||||1332|208.68|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|1332||||1332|732.6|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1332||||1332|919.08|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1332||||1332|287.66|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1332||||1332|223.5|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1332||||1332|166.92|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1332||||1332|92.89|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1332||||1332|208.68|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1332||||1332|166.92|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1332||||1332|92.89|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1332||||1332|92.89|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1332||||1332|919.08|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1332||||1332|92.89|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|Self-pay|Self-pay|1332||||1332|466.2|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1332||||1332|92.89|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1332||||1332|92.89|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1332||||1332|350|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1332||||1332|208.68|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1332||||1332|208.68|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1332||||1332|350|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1332||||1332|208.68|919.08|92.89
48393308|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO 2D W M-MODE LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1332||||1332|417.37|919.08|92.89
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AARP [1000]|AARP [100000]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AETNA [1015]|AETNA [101529]|2229||||2229|415.51|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2229||||2229|232.89|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS [1155]|BCBS UTHCT [115568]|2229||||2229|1047.63|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2229||||2229|171.63|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2229||||2229|1114.5|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2229||||2229|1404.27|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2229||||2229|232.89|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|CIGNA [1260]|CIGNA GWH [126023]|2229||||2229|1225.95|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2229||||2229|1538.01|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2229||||2229|603.61|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2229||||2229|415.51|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2229||||2229|232.89|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2229||||2229|415.51|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2229||||2229|232.89|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2229||||2229|232.89|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2229||||2229|1538.01|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2229||||2229|232.89|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|Self-pay|Self-pay|2229||||2229|780.15|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2229||||2229|232.89|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2229||||2229|232.89|1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2229||||2229||1538.01|171.63
48393312|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO TEE COMPLETE W/PF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2229||||2229||1538.01|171.63
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AARP [1000]|AARP [100000]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AETNA [1015]|AETNA [101529]|868||||868|90.24|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|868||||868|257.36|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS [1155]|BCBS UTHCT [115568]|868||||868|407.96|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|868||||868|44.66|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|868||||868|434|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|868||||868|546.84|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|868||||868|257.36|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|CIGNA [1260]|CIGNA GWH [126023]|868||||868|477.4|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|868||||868|598.92|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|868||||868|434|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|868||||868|90.24|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|868||||868|257.36|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|868||||868|90.24|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|868||||868|257.36|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|868||||868|257.36|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|868||||868|598.92|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|868||||868|257.36|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|Self-pay|Self-pay|868||||868|303.8|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|868||||868|257.36|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|868||||868|257.36|598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|868||||868||598.92|44.66
48393320|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO DOPPLER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|868||||868||598.92|44.66
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|AARP [1000]|AARP [100000]|683||||683|350|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|683||||683||471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|AETNA [1015]|AETNA [101529]|683||||683|44.83|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|683||||683|202.51|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|683||||683||471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|683||||683||471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|683||||683|321.01|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|683||||683|24.96|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|683||||683|341.5|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|683||||683|430.29|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|683||||683|202.51|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|683||||683||471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|683||||683|375.65|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|683||||683|471.27|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|683||||683|341.5|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|683||||683||471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|683||||683|44.83|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|683||||683|202.51|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|683||||683||471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|683||||683|44.83|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|683||||683|202.51|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|683||||683|202.51|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|683||||683|471.27|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|683||||683|202.51|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|Self-pay|Self-pay|683||||683|239.05|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|683||||683|202.51|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|683||||683|202.51|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|683||||683|350|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|683||||683||471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|683||||683||471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|683||||683|350|471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|683||||683||471.27|24.96
48393321|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHOCARD DOPPLER FOLLOW UP/LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|683||||683||471.27|24.96
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AARP [1000]|AARP [100000]|666||||666|350|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|666||||666||459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AETNA [1015]|AETNA [101529]|666||||666|42.05|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|666||||666|197.47|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|666||||666||459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|666||||666||459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BCBS UTHCT [115568]|666||||666|313.02|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|666||||666|28.02|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|666||||666|333|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|666||||666|419.58|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|666||||666|197.47|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|666||||666||459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|CIGNA [1260]|CIGNA GWH [126023]|666||||666|366.3|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|666||||666|459.54|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|666||||666|333|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|666||||666||459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|666||||666|42.05|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|666||||666|197.47|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|666||||666||459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|666||||666|42.05|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|666||||666|197.47|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|666||||666|197.47|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|666||||666|459.54|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|666||||666|197.47|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|Self-pay|Self-pay|666||||666|233.1|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|666||||666|197.47|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|666||||666|197.47|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|666||||666|350|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|666||||666||459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|666||||666||459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|666||||666|350|459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|666||||666||459.54|28.02
48393325|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO COLOR FLOW VELOCITY MAPPING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|666||||666||459.54|28.02
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|AARP [1000]|AARP [100000]|1730||||1730|350|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1730||||1730|442.27|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|AETNA [1015]|AETNA [101529]|1730||||1730|320.33|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1730||||1730|177.43|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1730||||1730|437.89|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1730||||1730|437.89|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|BCBS [1155]|BCBS UTHCT [115568]|1730||||1730|813.1|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1730||||1730|169.45|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1730||||1730|865|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1730||||1730|1089.9|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1730||||1730|177.43|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1730||||1730|437.89|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|CIGNA [1260]|CIGNA GWH [126023]|1730||||1730|951.5|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1730||||1730|1193.7|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1730||||1730|603.61|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1730||||1730|468.98|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1730||||1730|320.33|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1730||||1730|177.43|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1730||||1730|437.89|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1730||||1730|320.33|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1730||||1730|177.43|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1730||||1730|177.43|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1730||||1730|1193.7|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1730||||1730|177.43|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|Self-pay|Self-pay|1730||||1730|605.5|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1730||||1730|177.43|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1730||||1730|177.43|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1730||||1730|350|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1730||||1730|437.89|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1730||||1730|437.89|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1730||||1730|350|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1730||||1730|437.89|1193.7|169.45
48393350|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC ECHO REST & STRESS W/PF|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1730||||1730|875.79|1193.7|169.45
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|AARP [1000]|AARP [100000]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|AETNA [1015]|AETNA [101529]|1206||||1206|396.17|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1206||||1206|357.58|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|1206||||1206|566.82|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1206||||1206|184.77|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1206||||1206|603|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1206||||1206|759.78|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1206||||1206|357.58|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|1206||||1206|663.3|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1206||||1206|832.14|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1206||||1206|603.61|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1206||||1206|396.17|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1206||||1206|357.58|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1206||||1206|396.17|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1206||||1206|357.58|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1206||||1206|357.58|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1206||||1206|832.14|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1206||||1206|357.58|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|Self-pay|Self-pay|1206||||1206|422.1|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1206||||1206|357.58|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1206||||1206|357.58|832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1206||||1206||832.14|184.77
48393351|EAP|0483 - CARDIOLOGY-ECHOCARDIOLOGY|HC STRESS TTE COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1206||||1206||832.14|184.77
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.34||||4.34|1.91|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.34||||4.34|1.29|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.34||||4.34|2.04|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.34||||4.34|2.17|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.34||||4.34|2.17|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.34||||4.34|2.73|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.34||||4.34|1.29|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.34||||4.34|2.39|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.34||||4.34|2.99|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.34||||4.34|2.17|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.34||||4.34|1.91|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.34||||4.34|1.29|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.34||||4.34|1.91|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.34||||4.34|1.29|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.34||||4.34|1.29|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.34||||4.34|2.99|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.34||||4.34|1.29|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|Self-pay|Self-pay|4.34||||4.34|1.52|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.34||||4.34|1.29|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.34||||4.34|1.29|2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.34||||4.34||2.99|1.29
4854|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEDROXYPROGESTERONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.34||||4.34||2.99|1.29
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.73||||0.73|0.32|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.73||||0.73|0.22|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.73||||0.73|0.34|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.73||||0.73|0.37|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.73||||0.73|0.37|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.73||||0.73|0.46|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.73||||0.73|0.22|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.73||||0.73|0.4|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.73||||0.73|0.5|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.73||||0.73|0.37|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.73||||0.73|0.32|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.73||||0.73|0.22|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.73||||0.73|0.32|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.73||||0.73|0.22|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.73||||0.73|0.22|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.73||||0.73|0.5|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.73||||0.73|0.22|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|Self-pay|Self-pay|0.73||||0.73|0.26|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.73||||0.73|0.22|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.73||||0.73|0.22|0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.73||||0.73||0.5|0.22
4871|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MEGESTROL 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.73||||0.73||0.5|0.22
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|AARP [1000]|AARP [100000]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|AETNA [1015]|AETNA [101529]|0.87||||0.87|0.38|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.87||||0.87|0.26|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.87||||0.87|0.41|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.87||||0.87|0.44|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.87||||0.87|0.44|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.87||||0.87|0.55|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.87||||0.87|0.26|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.87||||0.87|0.48|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.87||||0.87|0.6|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.87||||0.87|0.44|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.87||||0.87|0.38|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.87||||0.87|0.26|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.87||||0.87|0.38|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.87||||0.87|0.26|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.87||||0.87|0.26|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.87||||0.87|0.6|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.87||||0.87|0.26|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|Self-pay|Self-pay|0.87||||0.87|0.3|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.87||||0.87|0.26|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.87||||0.87|0.26|0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.87||||0.87||0.6|0.26
4951|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG/5 ML ORAL SOLUTION|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.87||||0.87||0.6|0.26
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.94||||0.94|0.41|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.94||||0.94|0.28|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.94||||0.94|0.44|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.94||||0.94|0.47|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.94||||0.94|0.47|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.94||||0.94|0.59|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.94||||0.94|0.28|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.94||||0.94|0.52|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.94||||0.94|0.65|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.94||||0.94|0.47|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.94||||0.94|0.41|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.94||||0.94|0.28|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.94||||0.94|0.41|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.94||||0.94|0.28|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.94||||0.94|0.28|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.94||||0.94|0.65|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.94||||0.94|0.28|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.94||||0.94|0.33|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.94||||0.94|0.28|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.94||||0.94|0.28|0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.94||||0.94||0.65|0.28
4953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHADONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.94||||0.94||0.65|0.28
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.37||||0.37|0.16|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.37||||0.37|0.11|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.37||||0.37|0.17|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.37||||0.37|0.19|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.37||||0.37|0.19|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.37||||0.37|0.23|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.37||||0.37|0.11|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.37||||0.37|0.2|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.37||||0.37|0.26|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.37||||0.37|0.19|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.37||||0.37|0.16|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.37||||0.37|0.11|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.37||||0.37|0.16|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.37||||0.37|0.11|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.37||||0.37|0.11|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.37||||0.37|0.26|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.37||||0.37|0.11|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.37||||0.37|0.13|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.37||||0.37|0.11|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.37||||0.37|0.11|0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.37||||0.37||0.26|0.11
4971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.37||||0.37||0.26|0.11
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.45||||0.45|0.2|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.45||||0.45|0.13|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.45||||0.45|0.21|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.45||||0.45|0.23|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.45||||0.45|0.23|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.45||||0.45|0.28|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.45||||0.45|0.13|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.45||||0.45|0.25|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.45||||0.45|0.31|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.45||||0.45|0.23|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.45||||0.45|0.2|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.45||||0.45|0.13|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.45||||0.45|0.2|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.45||||0.45|0.13|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.45||||0.45|0.13|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.45||||0.45|0.31|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.45||||0.45|0.13|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|Self-pay|Self-pay|0.45||||0.45|0.16|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.45||||0.45|0.13|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.45||||0.45|0.13|0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.45||||0.45||0.31|0.13
4972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHOCARBAMOL 750 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.45||||0.45||0.31|0.13
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.45||||9.45|0.53|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.45||||9.45|2.8|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|9.45||||9.45|4.44|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.45||||9.45|0|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.45||||9.45|4.73|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.45||||9.45|5.95|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.45||||9.45|2.8|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|9.45||||9.45|5.2|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.45||||9.45|6.52|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.45||||9.45|0.18|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.45||||9.45|0.53|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.45||||9.45|2.8|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.45||||9.45|0.53|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.45||||9.45|2.8|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.45||||9.45|2.8|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.45||||9.45|6.52|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.45||||9.45|2.8|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|9.45||||9.45|3.31|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.45||||9.45|2.8|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.45||||9.45|2.8|6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.45||||9.45||6.52|0.18
4973|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHOTREXATE SODIUM 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.45||||9.45||6.52|0.18
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.48||||0.48|0.21|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.48||||0.48|0.14|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.48||||0.48|0.23|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.48||||0.48|0.24|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.48||||0.48|0.24|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.48||||0.48|0.3|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.48||||0.48|0.14|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.48||||0.48|0.26|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.48||||0.48|0.33|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.48||||0.48|0.24|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.48||||0.48|0.21|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.48||||0.48|0.14|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.48||||0.48|0.21|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.48||||0.48|0.14|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.48||||0.48|0.14|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.48||||0.48|0.33|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.48||||0.48|0.14|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.48||||0.48|0.17|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.48||||0.48|0.14|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.48||||0.48|0.14|0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.48||||0.48||0.33|0.14
4987|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.48||||0.48||0.33|0.14
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.84||||1.84|0.81|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.84||||1.84|0.55|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.84||||1.84|0.86|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.84||||1.84|0.92|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.84||||1.84|0.92|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.84||||1.84|1.16|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.84||||1.84|0.55|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.84||||1.84|1.01|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.84||||1.84|1.27|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.84||||1.84|0.92|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.84||||1.84|0.81|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.84||||1.84|0.55|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.84||||1.84|0.81|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.84||||1.84|0.55|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.84||||1.84|0.55|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.84||||1.84|1.27|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.84||||1.84|0.55|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.84||||1.84|0.64|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.84||||1.84|0.55|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.84||||1.84|0.55|1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.84||||1.84||1.27|0.55
4988|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYLPHENIDATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.84||||1.84||1.27|0.55
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|5.19||||5.19|0.82|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.19||||5.19|1.54|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|5.19||||5.19|2.44|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.19||||5.19|0|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.19||||5.19|2.6|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.19||||5.19|3.27|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.19||||5.19|1.54|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|5.19||||5.19|2.85|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|5.19||||5.19|3.58|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.19||||5.19|0.44|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.19||||5.19|0.82|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.19||||5.19|1.54|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.19||||5.19|0.82|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.19||||5.19|1.54|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.19||||5.19|1.54|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|5.19||||5.19|3.58|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.19||||5.19|1.54|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|Self-pay|Self-pay|5.19||||5.19|1.82|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.19||||5.19|1.54|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.19||||5.19|1.54|3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.19||||5.19||3.58|0.44
4993|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE 4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.19||||5.19||3.58|0.44
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|32.93||||32.93|8.78|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|32.93||||32.93||22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|32.93||||32.93|14.62|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|32.93||||32.93|9.76|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|32.93||||32.93||22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|32.93||||32.93||22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|32.93||||32.93|15.48|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|32.93||||32.93|0|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|32.93||||32.93|16.47|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|32.93||||32.93|20.75|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|32.93||||32.93|9.76|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|32.93||||32.93||22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|32.93||||32.93|18.11|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|32.93||||32.93|22.72|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|32.93||||32.93|7.25|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|32.93||||32.93||22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|32.93||||32.93|14.62|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|32.93||||32.93|9.76|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|32.93||||32.93||22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|32.93||||32.93|14.62|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|32.93||||32.93|9.76|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|32.93||||32.93|9.76|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|32.93||||32.93|22.72|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|32.93||||32.93|9.76|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|Self-pay|Self-pay|32.93||||32.93|11.53|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|32.93||||32.93|9.76|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|32.93||||32.93|9.76|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|32.93||||32.93|8.78|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|32.93||||32.93||22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|32.93||||32.93||22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|32.93||||32.93|8.78|22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|32.93||||32.93||22.72|7.25
4995|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|32.93||||32.93||22.72|7.25
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|57.14||||57.14|15.61|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57.14||||57.14||39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|57.14||||57.14|28.08|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57.14||||57.14|16.94|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57.14||||57.14||39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57.14||||57.14||39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|57.14||||57.14|26.86|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|57.14||||57.14|0|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57.14||||57.14|28.57|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|57.14||||57.14|36|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|57.14||||57.14|16.94|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57.14||||57.14||39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|57.14||||57.14|31.43|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|57.14||||57.14|39.43|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|57.14||||57.14|13.45|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57.14||||57.14||39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57.14||||57.14|28.08|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57.14||||57.14|16.94|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57.14||||57.14||39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57.14||||57.14|28.08|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57.14||||57.14|16.94|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|57.14||||57.14|16.94|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|57.14||||57.14|39.43|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57.14||||57.14|16.94|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|Self-pay|Self-pay|57.14||||57.14|20|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|57.14||||57.14|16.94|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|57.14||||57.14|16.94|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57.14||||57.14|15.61|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|57.14||||57.14||39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|57.14||||57.14||39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57.14||||57.14|15.61|39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57.14||||57.14||39.43|13.45
4996|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|METHYLPREDNISOLONE ACETATE 80 MG/ML SUSPENSION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|57.14||||57.14||39.43|13.45
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.48||||2.48|1.09|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.48||||2.48|0.74|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.48||||2.48|1.17|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.48||||2.48|1.24|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.48||||2.48|1.24|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.48||||2.48|1.56|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.48||||2.48|0.74|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.48||||2.48|1.36|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.48||||2.48|1.71|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.48||||2.48|1.24|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.48||||2.48|1.09|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.48||||2.48|0.74|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.48||||2.48|1.09|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.48||||2.48|0.74|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.48||||2.48|0.74|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.48||||2.48|1.71|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.48||||2.48|0.74|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|Self-pay|Self-pay|2.48||||2.48|0.87|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.48||||2.48|0.74|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.48||||2.48|0.74|1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.48||||2.48||1.71|0.74
5005|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.48||||2.48||1.71|0.74
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.34||||2.34|1.03|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.34||||2.34|0.69|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.34||||2.34|1.1|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.34||||2.34|1.17|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.34||||2.34|1.17|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.34||||2.34|1.47|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.34||||2.34|0.69|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.34||||2.34|1.29|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.34||||2.34|1.61|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.34||||2.34|1.17|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.34||||2.34|1.03|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.34||||2.34|0.69|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.34||||2.34|1.03|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.34||||2.34|0.69|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.34||||2.34|0.69|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.34||||2.34|1.61|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.34||||2.34|0.69|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.34||||2.34|0.82|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.34||||2.34|0.69|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.34||||2.34|0.69|1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.34||||2.34||1.61|0.69
5006|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.34||||2.34||1.61|0.69
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|3.28||||3.28|1.45|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.28||||3.28|0.97|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|3.28||||3.28|1.54|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.28||||3.28|1.64|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.28||||3.28|1.64|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.28||||3.28|2.07|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.28||||3.28|0.97|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|3.28||||3.28|1.8|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.28||||3.28|2.26|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.28||||3.28|1.64|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.28||||3.28|1.45|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.28||||3.28|0.97|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.28||||3.28|1.45|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.28||||3.28|0.97|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.28||||3.28|0.97|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.28||||3.28|2.26|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.28||||3.28|0.97|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|3.28||||3.28|1.15|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.28||||3.28|0.97|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.28||||3.28|0.97|2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.28||||3.28||2.26|0.97
5007|ERX|0250 - PHARMACY-GENERAL|METOPROLOL TARTRATE 5 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.28||||3.28||2.26|0.97
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.24||||0.24|0.11|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.24||||0.24|0.07|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.24||||0.24|0.11|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.24||||0.24|0.12|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.24||||0.24|0.12|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.24||||0.24|0.15|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.24||||0.24|0.07|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.24||||0.24|0.13|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.24||||0.24|0.17|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.24||||0.24|0.12|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.24||||0.24|0.11|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.24||||0.24|0.07|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.24||||0.24|0.11|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.24||||0.24|0.07|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.24||||0.24|0.07|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.24||||0.24|0.17|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.24||||0.24|0.07|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.24||||0.24|0.08|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.24||||0.24|0.07|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.24||||0.24|0.07|0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.24||||0.24||0.17|0.07
5009|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOPROLOL TARTRATE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.24||||0.24||0.17|0.07
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.25||||1.25|0.55|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.25||||1.25|0.37|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.25||||1.25|0.59|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.25||||1.25|0.63|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.25||||1.25|0.63|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.25||||1.25|0.79|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.25||||1.25|0.37|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.25||||1.25|0.69|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.25||||1.25|0.86|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.25||||1.25|0.63|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.25||||1.25|0.55|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.25||||1.25|0.37|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.25||||1.25|0.55|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.25||||1.25|0.37|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.25||||1.25|0.37|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.25||||1.25|0.86|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.25||||1.25|0.37|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|Self-pay|Self-pay|1.25||||1.25|0.44|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.25||||1.25|0.37|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.25||||1.25|0.37|0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.25||||1.25||0.86|0.37
5015|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.25||||1.25||0.86|0.37
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.59||||1.59|0.7|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.59||||1.59|0.47|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.59||||1.59|0.75|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.59||||1.59|0.8|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.59||||1.59|0.8|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.59||||1.59|1|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.59||||1.59|0.47|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.59||||1.59|0.87|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.59||||1.59|1.1|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.59||||1.59|0.8|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.59||||1.59|0.7|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.59||||1.59|0.47|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.59||||1.59|0.7|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.59||||1.59|0.47|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.59||||1.59|0.47|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.59||||1.59|1.1|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.59||||1.59|0.47|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|Self-pay|Self-pay|1.59||||1.59|0.56|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.59||||1.59|0.47|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.59||||1.59|0.47|1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.59||||1.59||1.1|0.47
5016|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METRONIDAZOLE 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.59||||1.59||1.1|0.47
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AARP [1000]|AARP [100000]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AETNA [1015]|AETNA [101529]|7.13||||7.13|3.14|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.13||||7.13|2.11|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BCBS UTHCT [115568]|7.13||||7.13|3.35|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.13||||7.13|3.57|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.13||||7.13|3.57|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.13||||7.13|4.49|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.13||||7.13|2.11|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|CIGNA [1260]|CIGNA GWH [126023]|7.13||||7.13|3.92|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.13||||7.13|4.92|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.13||||7.13|3.57|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.13||||7.13|3.14|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.13||||7.13|2.11|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.13||||7.13|3.14|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.13||||7.13|2.11|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.13||||7.13|2.11|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.13||||7.13|4.92|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.13||||7.13|2.11|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|Self-pay|Self-pay|7.13||||7.13|2.5|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.13||||7.13|2.11|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.13||||7.13|2.11|4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.13||||7.13||4.92|2.11
5018|ERX|0250 - PHARMACY-GENERAL|METRONIDAZOLE 500 MG/100 ML-SODIUM CHLORIDE(ISO) INTRAVENOUS PIGGYBACK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.13||||7.13||4.92|2.11
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AARP [1000]|AARP [100000]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AARP [1000]|AARP [100000]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AETNA [1015]|AETNA [101529]|0.52||||0.52|0.23|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AETNA [1015]|AETNA [101529]|0.52||||0.52|0.23|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BCBS UTHCT [115568]|0.52||||0.52|0.24|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BCBS UTHCT [115568]|0.52||||0.52|0.24|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.52||||0.52|0.26|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.52||||0.52|0.26|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.52||||0.52|0.26|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.52||||0.52|0.26|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.52||||0.52|0.33|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.52||||0.52|0.33|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA [1260]|CIGNA GWH [126023]|0.52||||0.52|0.29|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|CIGNA [1260]|CIGNA GWH [126023]|0.52||||0.52|0.29|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.52||||0.52|0.36|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.52||||0.52|0.36|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.52||||0.52|0.26|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.52||||0.52|0.26|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.52||||0.52|0.23|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.52||||0.52|0.23|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.52||||0.52|0.23|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.52||||0.52|0.23|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.52||||0.52|0.36|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.52||||0.52|0.36|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|Self-pay|Self-pay|0.52||||0.52|0.18|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|Self-pay|Self-pay|0.52||||0.52|0.18|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.52||||0.52|0.15|0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.52||||0.52||0.36|0.15
5086|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ORAL REPACK|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.52||||0.52||0.36|0.15
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|AARP [1000]|AARP [100000]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|AETNA [1015]|AETNA [101529]|5.36||||5.36|2.36|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.36||||5.36|1.59|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|BCBS [1155]|BCBS UTHCT [115568]|5.36||||5.36|2.52|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.36||||5.36|2.68|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.36||||5.36|2.68|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.36||||5.36|3.38|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.36||||5.36|1.59|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|CIGNA [1260]|CIGNA GWH [126023]|5.36||||5.36|2.95|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.36||||5.36|3.7|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.36||||5.36|2.68|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.36||||5.36|2.36|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.36||||5.36|1.59|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.36||||5.36|2.36|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.36||||5.36|1.59|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.36||||5.36|1.59|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.36||||5.36|3.7|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.36||||5.36|1.59|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|Self-pay|Self-pay|5.36||||5.36|1.88|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.36||||5.36|1.59|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.36||||5.36|1.59|3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.36||||5.36||3.7|1.59
5087|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINERAL OIL ENEMA|133 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.36||||5.36||3.7|1.59
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|AARP [1000]|AARP [100000]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|AETNA [1015]|AETNA [101529]|52||||52|0|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|52||||52|15.42|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|BCBS [1155]|BCBS UTHCT [115568]|52||||52|0|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|52||||52|10.94|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|52||||52|0|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|52||||52|0|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|52||||52|15.42|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|CIGNA [1260]|CIGNA GWH [126023]|52||||52|0|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|52||||52|35.88|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|52||||52|26|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|52||||52|0|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|52||||52|15.42|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|52||||52|0|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|52||||52|15.42|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|52||||52|15.42|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|52||||52|35.88|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|52||||52|15.42|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|Self-pay|Self-pay|52||||52|18.2|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|52||||52|15.42|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|52||||52|15.42|35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|52||||52||35.88|10.94
51000102|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PROSTATE CA SCREENING; DRE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|52||||52||35.88|10.94
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|AARP [1000]|AARP [100000]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|AETNA [1015]|AETNA [101529]|513||||513|0|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|513||||513|152.1|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|BCBS [1155]|BCBS UTHCT [115568]|513||||513|0|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|513||||513|138.7|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|513||||513|0|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|513||||513|0|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|513||||513|152.1|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|CIGNA [1260]|CIGNA GWH [126023]|513||||513|0|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|513||||513|353.97|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|513||||513|148.43|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|513||||513|0|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|513||||513|152.1|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|513||||513|0|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|513||||513|152.1|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|513||||513|152.1|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|513||||513|353.97|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|513||||513|152.1|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|Self-pay|Self-pay|513||||513|179.55|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|513||||513|152.1|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|513||||513|152.1|353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|513||||513||353.97|138.7
51000248|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEMONSTRATE USE HOME INR MON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|513||||513||353.97|138.7
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|AARP [1000]|AARP [100000]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|AETNA [1015]|AETNA [101529]|70||||70|0|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70||||70|20.76|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|BCBS [1155]|BCBS UTHCT [115568]|70||||70|0|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70||||70|0|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70||||70|0|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70||||70|0|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70||||70|20.76|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|CIGNA [1260]|CIGNA GWH [126023]|70||||70|0|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70||||70|48.3|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70||||70|32.79|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70||||70|0|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70||||70|20.76|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70||||70|0|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70||||70|20.76|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70||||70|20.76|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70||||70|48.3|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70||||70|20.76|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|Self-pay|Self-pay|70||||70|24.5|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70||||70|20.76|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70||||70|20.76|48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70||||70||48.3|20.76
51000444|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC DEPRESSION SCREEN ANNUAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70||||70||48.3|20.76
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|AARP [1000]|AARP [100000]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|AETNA [1015]|AETNA [101529]|102||||102|0|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102||||102|30.24|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|BCBS [1155]|BCBS UTHCT [115568]|102||||102|0|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102||||102|45.18|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102||||102|0|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102||||102|0|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102||||102|30.24|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|CIGNA [1260]|CIGNA GWH [126023]|102||||102|0|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|102||||102|70.38|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102||||102|50|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102||||102|0|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102||||102|30.24|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102||||102|0|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102||||102|30.24|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|102||||102|30.24|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|102||||102|70.38|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102||||102|30.24|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|Self-pay|Self-pay|102||||102|35.7|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102||||102|30.24|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102||||102|30.24|70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102||||102||70.38|30.24
51095115|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 1 INJ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|AARP [1000]|AARP [100000]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|AETNA [1015]|AETNA [101529]|102||||102|0|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102||||102|30.24|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|BCBS [1155]|BCBS UTHCT [115568]|102||||102|0|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102||||102|45.18|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102||||102|0|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102||||102|0|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102||||102|30.24|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|CIGNA [1260]|CIGNA GWH [126023]|102||||102|0|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|GROUP PENSION ADMIN [1450]|GPA [145000]|102||||102|70.38|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102||||102|50|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102||||102|0|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102||||102|30.24|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102||||102|0|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102||||102|30.24|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|102||||102|30.24|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|PHCS [1780]|PHCS MULTIPLAN [178000]|102||||102|70.38|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102||||102|30.24|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|Self-pay|Self-pay|102||||102|35.7|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102||||102|30.24|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102||||102|30.24|70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102||||102||70.38|30.24
51095117|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ALLG IMMNTX X W/PRV ALLGIC XTRCS 2+ INJ|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|AARP [1000]|AARP [100000]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|AETNA [1015]|AETNA [101529]|102||||102|0|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102||||102|30.24|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|BCBS [1155]|BCBS UTHCT [115568]|102||||102|0|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102||||102|45.18|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102||||102|0|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102||||102|0|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102||||102|30.24|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|CIGNA [1260]|CIGNA GWH [126023]|102||||102|0|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|102||||102|70.38|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102||||102|50|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102||||102|0|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102||||102|30.24|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102||||102|0|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102||||102|30.24|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|102||||102|30.24|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|102||||102|70.38|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102||||102|30.24|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|Self-pay|Self-pay|102||||102|35.7|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102||||102|30.24|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102||||102|30.24|70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102||||102||70.38|30.24
51095165|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC PREPJ& ALLERGEN IMMUNOTHERAPY 1/MLT ANTIGEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102||||102||70.38|30.24
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AARP [1000]|AARP [100000]|297||||297|133.65|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|297||||297|108.75|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AETNA [1015]|AETNA [101529]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|297||||297|107.68|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|297||||297|107.68|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS [1155]|BCBS UTHCT [115568]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|297||||297|138.7|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|297||||297|107.68|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|CIGNA [1260]|CIGNA GWH [126023]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|297||||297|204.93|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|297||||297|148.5|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|297||||297|115.32|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|297||||297|107.68|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|297||||297|204.93|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|Self-pay|Self-pay|297||||297|103.95|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|297||||297|0|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|297||||297|88.06|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|297||||297|133.65|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|297||||297|107.68|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|297||||297|107.68|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|297||||297|133.65|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|297||||297|107.68|204.93|17.64
51099211|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CLINIC VISIT LEVEL 1 EST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|297||||297|17.64|204.93|17.64
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|AARP [1000]|AARP [100000]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|AETNA [1015]|AETNA [101529]|212||||212|0|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|212||||212|62.86|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|BCBS [1155]|BCBS UTHCT [115568]|212||||212|0|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|212||||212|39.85|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|212||||212|0|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|212||||212|0|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|212||||212|62.86|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|CIGNA [1260]|CIGNA GWH [126023]|212||||212|0|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|212||||212|146.28|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|212||||212|93.59|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|212||||212|0|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|212||||212|62.86|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|212||||212|0|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|212||||212|62.86|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|212||||212|62.86|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|212||||212|146.28|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|212||||212|62.86|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|Self-pay|Self-pay|212||||212|74.2|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|212||||212|62.86|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|212||||212|62.86|146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|212||||212||146.28|39.85
51099490|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC CHRON CARE MANAGEMENT SRVC 20 MIN PER MONTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|212||||212||146.28|39.85
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|AARP [1000]|AARP [100000]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|AETNA [1015]|AETNA [101529]|313||||313|0|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|313||||313|92.8|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|BCBS [1155]|BCBS UTHCT [115568]|313||||313|0|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|313||||313|138.7|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|313||||313|0|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|313||||313|0|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|313||||313|92.8|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|CIGNA [1260]|CIGNA GWH [126023]|313||||313|0|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|313||||313|215.97|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|313||||313|148.43|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|313||||313|0|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|313||||313|92.8|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|313||||313|0|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|313||||313|92.8|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|313||||313|92.8|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|313||||313|215.97|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|313||||313|92.8|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|Self-pay|Self-pay|313||||313|109.55|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|313||||313|92.8|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|313||||313|92.8|215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|313||||313||215.97|92.8
51099495|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANS CARE MGMT 14 DAY DISCH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|AARP [1000]|AARP [100000]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|AETNA [1015]|AETNA [101529]|313||||313|0|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|313||||313|92.8|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|BCBS [1155]|BCBS UTHCT [115568]|313||||313|0|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|313||||313|138.7|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|313||||313|0|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|313||||313|0|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|313||||313|92.8|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|CIGNA [1260]|CIGNA GWH [126023]|313||||313|0|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|313||||313|215.97|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|313||||313|148.43|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|313||||313|0|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|313||||313|92.8|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|313||||313|0|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|313||||313|92.8|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|313||||313|92.8|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|313||||313|215.97|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|313||||313|92.8|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|Self-pay|Self-pay|313||||313|109.55|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|313||||313|92.8|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|313||||313|92.8|215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|313||||313||215.97|92.8
51099496|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC TRANSITIONAL CARE MANAGE SRVC 7 DAY DISCHARGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|313||||313||215.97|92.8
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|AARP [1000]|AARP [100000]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|AETNA [1015]|AETNA [101529]|236||||236|0|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|236||||236|69.97|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|BCBS [1155]|BCBS UTHCT [115568]|236||||236|0|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|236||||236|87.77|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|236||||236|0|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|236||||236|0|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|236||||236|69.97|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|CIGNA [1260]|CIGNA GWH [126023]|236||||236|0|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|236||||236|162.84|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|236||||236|93.59|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|236||||236|0|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|236||||236|69.97|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|236||||236|0|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|236||||236|69.97|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|236||||236|69.97|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|236||||236|162.84|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|236||||236|69.97|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|Self-pay|Self-pay|236||||236|82.6|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|236||||236|69.97|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|236||||236|69.97|162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|236||||236||162.84|69.97
51099497|EAP|0510 - CLINIC-GENERAL CLASSIFICATION|HC ADVANCE CARE PLANNING FIRST 30 MINS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|236||||236||162.84|69.97
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.83||||0.83|0.37|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.83||||0.83|0.25|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.83||||0.83|0.39|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.83||||0.83|0.42|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.83||||0.83|0.42|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.83||||0.83|0.52|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.83||||0.83|0.25|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.83||||0.83|0.46|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.83||||0.83|0.57|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.83||||0.83|0.42|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.83||||0.83|0.37|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.83||||0.83|0.25|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.83||||0.83|0.37|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.83||||0.83|0.25|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.83||||0.83|0.25|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.83||||0.83|0.57|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.83||||0.83|0.25|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.83||||0.83|0.29|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.83||||0.83|0.25|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.83||||0.83|0.25|0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.83||||0.83||0.57|0.25
5111|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOCYCLINE 50 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.83||||0.83||0.57|0.25
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.99||||1.99|0.88|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.99||||1.99|0.59|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.99||||1.99|0.94|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.99||||1.99|1|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.99||||1.99|1|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.99||||1.99|1.25|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.99||||1.99|0.59|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.99||||1.99|1.09|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.99||||1.99|1.37|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.99||||1.99|1|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.99||||1.99|0.88|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.99||||1.99|0.59|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.99||||1.99|0.88|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.99||||1.99|0.59|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.99||||1.99|0.59|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.99||||1.99|1.37|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.99||||1.99|0.59|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.99||||1.99|0.7|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.99||||1.99|0.59|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.99||||1.99|0.59|1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.99||||1.99||1.37|0.59
5114|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.99||||1.99||1.37|0.59
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.66||||0.66|0.29|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.66||||0.66|0.2|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.66||||0.66|0.31|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.66||||0.66|0.33|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.66||||0.66|0.33|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.66||||0.66|0.42|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.66||||0.66|0.2|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.66||||0.66|0.36|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.66||||0.66|0.46|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.66||||0.66|0.33|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.66||||0.66|0.29|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.66||||0.66|0.2|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.66||||0.66|0.29|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.66||||0.66|0.2|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.66||||0.66|0.2|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.66||||0.66|0.46|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.66||||0.66|0.2|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.66||||0.66|0.23|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.66||||0.66|0.2|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.66||||0.66|0.2|0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.66||||0.66||0.46|0.2
5115|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MINOXIDIL 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.66||||0.66||0.46|0.2
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|8.9||||8.9|5.25|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.9||||8.9||8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|8.9||||8.9|8.9|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.9||||8.9|2.64|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.9||||8.9||8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.9||||8.9||8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|8.9||||8.9|4.18|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.9||||8.9|0|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.9||||8.9|4.45|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.9||||8.9|5.61|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.9||||8.9|2.64|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.9||||8.9||8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|8.9||||8.9|4.9|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.9||||8.9|6.14|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.9||||8.9|3.94|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.9||||8.9||8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.9||||8.9|8.9|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.9||||8.9|2.64|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.9||||8.9||8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.9||||8.9|8.9|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.9||||8.9|2.64|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.9||||8.9|2.64|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.9||||8.9|6.14|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.9||||8.9|2.64|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|8.9||||8.9|3.11|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.9||||8.9|2.64|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.9||||8.9|2.64|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.9||||8.9|5.25|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.9||||8.9||8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.9||||8.9||8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.9||||8.9|5.25|8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.9||||8.9||8.9|2.64
5173|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MORPHINE 5 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.9||||8.9||8.9|2.64
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AARP [1000]|AARP [100000]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.34||||1.34|0.59|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.34||||1.34|0.4|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.34||||1.34|0.63|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.34||||1.34|0.67|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.34||||1.34|0.67|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.34||||1.34|0.84|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.34||||1.34|0.4|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.34||||1.34|0.74|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.34||||1.34|0.92|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.34||||1.34|0.67|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.34||||1.34|0.59|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.34||||1.34|0.4|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.34||||1.34|0.59|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.34||||1.34|0.4|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.34||||1.34|0.4|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.34||||1.34|0.92|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.34||||1.34|0.4|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|Self-pay|Self-pay|1.34||||1.34|0.47|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.34||||1.34|0.4|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.34||||1.34|0.4|0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.34||||1.34||0.92|0.4
5178|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|MORPHINE 15 MG IMMEDIATE RELEASE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.34||||1.34||0.92|0.4
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|AARP [1000]|AARP [100000]|42||||42|0|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|42||||42||30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|AETNA [1015]|AETNA [101529]|42||||42|18.52|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42||||42|12.45|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42||||42||30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|42||||42||30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|BCBS [1155]|BCBS UTHCT [115568]|42||||42|0|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|42||||42|24.52|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|42||||42|0|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|42||||42|0|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|42||||42|12.45|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|42||||42||30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|CIGNA [1260]|CIGNA GWH [126023]|42||||42|0|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|42||||42|28.98|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|42||||42|30.84|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|42||||42||30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42||||42|18.52|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42||||42|12.45|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42||||42||30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42||||42|18.52|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|42||||42|12.45|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|42||||42|12.45|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|42||||42|28.98|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42||||42|12.45|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|Self-pay|Self-pay|42||||42|14.7|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|42||||42|12.45|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|42||||42|12.45|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42||||42|0|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|42||||42||30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|42||||42||30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42||||42|0|30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42||||42||30.84|12.45
52100091|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC OBTAINING SCREEN PAP SMEAR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|42||||42||30.84|12.45
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|AARP [1000]|AARP [100000]|110||||110|0|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|110||||110||148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|AETNA [1015]|AETNA [101529]|110||||110|48.51|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|110||||110|32.62|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|110||||110||148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|110||||110||148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|BCBS [1155]|BCBS UTHCT [115568]|110||||110|0|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|110||||110|110|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|110||||110|0|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|110||||110|0|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|110||||110|32.62|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|110||||110||148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|CIGNA [1260]|CIGNA GWH [126023]|110||||110|0|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|110||||110|75.9|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|110||||110|148.43|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|110||||110||148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|110||||110|48.51|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|110||||110|32.62|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|110||||110||148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|110||||110|48.51|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|110||||110|32.62|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|110||||110|32.62|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|110||||110|75.9|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|110||||110|32.62|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|Self-pay|Self-pay|110||||110|38.5|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|110||||110|32.62|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|110||||110|32.62|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|110||||110|0|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|110||||110||148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|110||||110||148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|110||||110|0|148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|110||||110||148.43|32.62
52100245|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL FOOT EXAM PT LOPS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|110||||110||148.43|32.62
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|AARP [1000]|AARP [100000]|134||||134|0|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|134||||134||148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|AETNA [1015]|AETNA [101529]|134||||134|59.09|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|134||||134|39.73|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|134||||134||148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|134||||134||148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|BCBS [1155]|BCBS UTHCT [115568]|134||||134|0|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|134||||134|134|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|134||||134|0|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|134||||134|0|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|134||||134|39.73|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|134||||134||148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|CIGNA [1260]|CIGNA GWH [126023]|134||||134|0|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|134||||134|92.46|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|134||||134|148.43|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|134||||134||148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|134||||134|59.09|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|134||||134|39.73|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|134||||134||148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|134||||134|59.09|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|134||||134|39.73|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|134||||134|39.73|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|134||||134|92.46|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|134||||134|39.73|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|Self-pay|Self-pay|134||||134|46.9|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|134||||134|39.73|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|134||||134|39.73|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|134||||134|0|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|134||||134||148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|134||||134||148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|134||||134|0|148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|134||||134||148.43|39.73
52100246|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC FOLLOW-UP EVAL OF FOOT PT LOPS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|134||||134||148.43|39.73
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|AARP [1000]|AARP [100000]|112||||112|0|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|112||||112||224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|AETNA [1015]|AETNA [101529]|112||||112|49.39|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|112||||112|33.21|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|112||||112||224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|112||||112||224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|BCBS [1155]|BCBS UTHCT [115568]|112||||112|0|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|112||||112|0|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|112||||112|0|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|112||||112|0|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|112||||112|33.21|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|112||||112||224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|CIGNA [1260]|CIGNA GWH [126023]|112||||112|0|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|112||||112|77.28|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|112||||112|224.44|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|112||||112||224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|112||||112|49.39|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|112||||112|33.21|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|112||||112||224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|112||||112|49.39|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|112||||112|33.21|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|112||||112|33.21|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|112||||112|77.28|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|112||||112|33.21|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|Self-pay|Self-pay|112||||112|39.2|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|112||||112|33.21|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|112||||112|33.21|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|112||||112|0|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|112||||112||224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|112||||112||224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|112||||112|0|224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|112||||112||224.44|33.21
52100247|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC ROUTINE FOOT CARE PT W/LOPS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|112||||112||224.44|33.21
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|AARP [1000]|AARP [100000]|178||||178|0|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|178||||178||148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|AETNA [1015]|AETNA [101529]|178||||178|78.5|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|178||||178|52.78|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|178||||178||148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|178||||178||148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|BCBS [1155]|BCBS UTHCT [115568]|178||||178|0|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|178||||178|138.7|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|178||||178|0|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|178||||178|0|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|178||||178|52.78|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|178||||178||148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|CIGNA [1260]|CIGNA GWH [126023]|178||||178|0|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|178||||178|122.82|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|178||||178|148.43|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|178||||178||148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|178||||178|78.5|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|178||||178|52.78|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|178||||178||148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|178||||178|78.5|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|178||||178|52.78|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|178||||178|52.78|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|178||||178|122.82|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|178||||178|52.78|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|Self-pay|Self-pay|178||||178|62.3|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|178||||178|52.78|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|178||||178|52.78|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|178||||178|0|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|178||||178||148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|178||||178||148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|178||||178|0|148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|178||||178||148.43|52.78
52100402|EAP|0521 - FREESTANDING CLINIC-CLINIC VISIT BY MEMBER|HC INITIAL PREVENTIVE EXAM NEW BENE 1ST 12 MTHS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|178||||178||148.43|52.78
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AARP [1000]|AARP [100000]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AETNA [1015]|AETNA [101529]|70.25||||70.25|30.98|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70.25||||70.25|20.83|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BCBS UTHCT [115568]|70.25||||70.25|33.02|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70.25||||70.25|35.13|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70.25||||70.25|35.13|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70.25||||70.25|44.26|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70.25||||70.25|20.83|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|CIGNA [1260]|CIGNA GWH [126023]|70.25||||70.25|38.64|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|70.25||||70.25|48.47|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70.25||||70.25|35.13|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70.25||||70.25|30.98|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70.25||||70.25|20.83|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70.25||||70.25|30.98|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70.25||||70.25|20.83|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|70.25||||70.25|20.83|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|70.25||||70.25|48.47|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70.25||||70.25|20.83|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|Self-pay|Self-pay|70.25||||70.25|24.59|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70.25||||70.25|20.83|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70.25||||70.25|20.83|48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70.25||||70.25||48.47|20.83
5335|ERX|0250 - PHARMACY-GENERAL|NAFCILLIN 2 GRAM SOLUTION FOR INJECTION|2,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70.25||||70.25||48.47|20.83
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|49.08||||49.08|34.13|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49.08||||49.08|14.55|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|49.08||||49.08|23.07|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49.08||||49.08|0|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49.08||||49.08|24.54|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49.08||||49.08|30.92|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49.08||||49.08|14.55|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|49.08||||49.08|26.99|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|49.08||||49.08|33.87|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|49.08||||49.08|14.93|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49.08||||49.08|34.13|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49.08||||49.08|14.55|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49.08||||49.08|34.13|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49.08||||49.08|14.55|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|49.08||||49.08|14.55|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|49.08||||49.08|33.87|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49.08||||49.08|14.55|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|49.08||||49.08|17.18|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|49.08||||49.08|14.55|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49.08||||49.08|14.55|34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49.08||||49.08||34.13|14.55
5373|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|NALOXONE 0.4 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49.08||||49.08||34.13|14.55
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.27||||0.27|0.12|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.27||||0.27|0.08|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.27||||0.27|0.13|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.27||||0.27|0.14|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.27||||0.27|0.14|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.27||||0.27|0.17|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.27||||0.27|0.08|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.27||||0.27|0.15|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.27||||0.27|0.19|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.27||||0.27|0.14|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.27||||0.27|0.12|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.27||||0.27|0.08|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.27||||0.27|0.12|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.27||||0.27|0.08|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.27||||0.27|0.08|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.27||||0.27|0.19|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.27||||0.27|0.08|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|Self-pay|Self-pay|0.27||||0.27|0.09|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.27||||0.27|0.08|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.27||||0.27|0.08|0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.27||||0.27||0.19|0.08
5391|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.27||||0.27||0.19|0.08
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.38||||0.38|0.17|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.38||||0.38|0.11|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.38||||0.38|0.18|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.38||||0.38|0.19|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.38||||0.38|0.19|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.38||||0.38|0.24|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.38||||0.38|0.11|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.38||||0.38|0.21|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.38||||0.38|0.26|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.38||||0.38|0.19|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.38||||0.38|0.17|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.38||||0.38|0.11|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.38||||0.38|0.17|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.38||||0.38|0.11|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.38||||0.38|0.11|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.38||||0.38|0.26|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.38||||0.38|0.11|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.38||||0.38|0.13|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.38||||0.38|0.11|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.38||||0.38|0.11|0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.38||||0.38||0.26|0.11
5393|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NAPROXEN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.38||||0.38||0.26|0.11
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.16||||3.16|1.39|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.16||||3.16|0.94|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.16||||3.16|1.49|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.16||||3.16|1.58|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.16||||3.16|1.58|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.16||||3.16|1.99|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.16||||3.16|0.94|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.16||||3.16|1.74|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.16||||3.16|2.18|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.16||||3.16|1.58|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.16||||3.16|1.39|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.16||||3.16|0.94|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.16||||3.16|1.39|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.16||||3.16|0.94|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.16||||3.16|0.94|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.16||||3.16|2.18|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.16||||3.16|0.94|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|3.16||||3.16|1.11|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.16||||3.16|0.94|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.16||||3.16|0.94|2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.16||||3.16||2.18|0.94
5472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.16||||3.16||2.18|0.94
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AARP [1000]|AARP [100000]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AETNA [1015]|AETNA [101529]|158.26||||158.26|69.79|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|158.26||||158.26|46.92|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS [1155]|BCBS UTHCT [115568]|158.26||||158.26|74.38|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|158.26||||158.26|79.13|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|158.26||||158.26|79.13|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|158.26||||158.26|99.7|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|158.26||||158.26|46.92|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|CIGNA [1260]|CIGNA GWH [126023]|158.26||||158.26|87.04|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|158.26||||158.26|109.2|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|158.26||||158.26|79.13|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|158.26||||158.26|69.79|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|158.26||||158.26|46.92|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|158.26||||158.26|69.79|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|158.26||||158.26|46.92|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|158.26||||158.26|46.92|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|158.26||||158.26|109.2|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|158.26||||158.26|46.92|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|Self-pay|Self-pay|158.26||||158.26|55.39|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|158.26||||158.26|46.92|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|158.26||||158.26|46.92|109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|158.26||||158.26||109.2|46.92
5474|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEOMYCIN 1.75 MG-POLYMYXIN 10,000 UNIT-GRAMICIDIN 0.025MG/ML EYE DROPS|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|158.26||||158.26||109.2|46.92
5510001|EAP||HH RN INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||127.81|60.07|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|63.91|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|80.52|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|Self-pay|Self-pay|||||127.81|44.73|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||127.81||80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||127.81||80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||80.52|44.73
5510001|EAP||HH RN INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||127.81|60.07|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|63.91|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|80.52|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|Self-pay|Self-pay|||||127.81|44.73|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||80.52|44.73
5510002|EAP||HH RN ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AARP [1000]|AARP [100000]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AETNA [1015]|AETNA [101529]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BCBS UTHCT [115568]|||||127.81|60.07|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|63.91|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|80.52|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|CIGNA [1260]|CIGNA GWH [126023]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|Self-pay|Self-pay|||||127.81|44.73|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||80.52|44.73
5510003|EAP||HH RN MANAGEMENT AND EVALUATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AARP [1000]|AARP [100000]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AETNA [1015]|AETNA [101529]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BCBS UTHCT [115568]|||||127.81|60.07|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|63.91|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|80.52|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|CIGNA [1260]|CIGNA GWH [126023]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|Self-pay|Self-pay|||||127.81|44.73|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||80.52|44.73
5510004|EAP||HH RN OBSERVATION AND ASSESSMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AARP [1000]|AARP [100000]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AETNA [1015]|AETNA [101529]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BCBS UTHCT [115568]|||||127.81|60.07|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|63.91|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|80.52|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|CIGNA [1260]|CIGNA GWH [126023]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|Self-pay|Self-pay|||||127.81|44.73|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||80.52|44.73
5510005|EAP||HH RN TRAINING AND EDUCATION|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AARP [1000]|AARP [100000]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AETNA [1015]|AETNA [101529]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BCBS UTHCT [115568]|||||127.81|60.07|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||127.81|63.91|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||127.81|63.91|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||127.81|80.52|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|CIGNA [1260]|CIGNA GWH [126023]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|Self-pay|Self-pay|||||127.81|44.73|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||127.81|0|80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||127.81||80.52|44.73
5510006|EAP||Hh/hspc Lpn Routine Visit|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||127.81||80.52|44.73
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.07||||0.07|0.03|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.07||||0.07|0.02|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.07||||0.07|0.03|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.07||||0.07|0.04|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.07||||0.07|0.04|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.07||||0.07|0.04|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.07||||0.07|0.02|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.07||||0.07|0.04|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.07||||0.07|0.05|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.07||||0.07|0.04|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.07||||0.07|0.03|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.07||||0.07|0.02|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.07||||0.07|0.03|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.07||||0.07|0.02|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.07||||0.07|0.02|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.07||||0.07|0.05|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.07||||0.07|0.02|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.07||||0.07|0.02|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.07||||0.07|0.02|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.07||||0.07|0.02|0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.07||||0.07||0.05|0.02
5542|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NIACIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.07||||0.07||0.05|0.02
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|44.24||||44.24|19.51|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.24||||44.24|13.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|44.24||||44.24|20.79|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.24||||44.24|22.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.24||||44.24|22.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.24||||44.24|27.87|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.24||||44.24|13.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|44.24||||44.24|24.33|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|44.24||||44.24|30.53|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|44.24||||44.24|22.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.24||||44.24|19.51|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.24||||44.24|13.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.24||||44.24|19.51|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.24||||44.24|13.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|44.24||||44.24|13.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|44.24||||44.24|30.53|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.24||||44.24|13.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|44.24||||44.24|15.48|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|44.24||||44.24|13.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.24||||44.24|13.12|30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.24||||44.24||30.53|13.12
5599|ERX|0250 - PHARMACY-GENERAL|NITROGLYCERIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.24||||44.24||30.53|13.12
5600001|EAP||HH MSW INITIAL VISIT|1|AARP [1000]|AARP [100000]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||204.87||129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|AETNA [1015]|AETNA [101529]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||204.87||129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||204.87||129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||204.87|96.29|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||204.87|102.44|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||204.87|102.44|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||204.87|129.07|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||204.87||129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||204.87||129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||204.87||129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|Self-pay|Self-pay|||||204.87|71.7|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||204.87||129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||204.87||129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||204.87|0|129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||204.87||129.07|71.7
5600001|EAP||HH MSW INITIAL VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||204.87||129.07|71.7
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AARP [1000]|AARP [100000]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.55||||2.55|1.12|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.55||||2.55|0.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.55||||2.55|1.2|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.55||||2.55|1.28|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.55||||2.55|1.28|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.55||||2.55|1.61|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.55||||2.55|0.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.55||||2.55|1.4|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.55||||2.55|1.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.55||||2.55|1.28|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.55||||2.55|1.12|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.55||||2.55|0.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.55||||2.55|1.12|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.55||||2.55|0.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.55||||2.55|0.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.55||||2.55|1.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.55||||2.55|0.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|Self-pay|Self-pay|2.55||||2.55|0.89|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.55||||2.55|0.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.55||||2.55|0.76|1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.55||||2.55||1.76|0.76
5604|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 0.4 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.55||||2.55||1.76|0.76
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AARP [1000]|AARP [100000]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AETNA [1015]|AETNA [101529]|6.84||||6.84|3.02|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.84||||6.84|2.03|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BCBS UTHCT [115568]|6.84||||6.84|3.21|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.84||||6.84|3.42|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.84||||6.84|3.42|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.84||||6.84|4.31|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.84||||6.84|2.03|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|CIGNA [1260]|CIGNA GWH [126023]|6.84||||6.84|3.76|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|6.84||||6.84|4.72|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.84||||6.84|3.42|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.84||||6.84|3.02|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.84||||6.84|2.03|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.84||||6.84|3.02|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.84||||6.84|2.03|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.84||||6.84|2.03|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|6.84||||6.84|4.72|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.84||||6.84|2.03|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|Self-pay|Self-pay|6.84||||6.84|2.39|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.84||||6.84|2.03|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.84||||6.84|2.03|4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.84||||6.84||4.72|2.03
5606|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NITROGLYCERIN 2 % TRANSDERMAL OINTMENT|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.84||||6.84||4.72|2.03
5610001|EAP||HH MSW ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||204.87||129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||204.87||129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||204.87||129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||204.87|96.29|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||204.87|102.44|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||204.87|102.44|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||204.87|129.07|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||204.87||129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||204.87||129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||204.87||129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|Self-pay|Self-pay|||||204.87|71.7|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||204.87||129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||204.87||129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||204.87|0|129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||204.87||129.07|71.7
5610001|EAP||HH MSW ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||204.87||129.07|71.7
5710001|EAP||HH HHA VISIT|1|AARP [1000]|AARP [100000]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||57.88||36.46|20.26
5710001|EAP||HH HHA VISIT|1|AETNA [1015]|AETNA [101529]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||57.88||36.46|20.26
5710001|EAP||HH HHA VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||57.88||36.46|20.26
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||57.88|27.2|36.46|20.26
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||57.88|28.94|36.46|20.26
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||57.88|28.94|36.46|20.26
5710001|EAP||HH HHA VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||57.88|36.46|36.46|20.26
5710001|EAP||HH HHA VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||57.88||36.46|20.26
5710001|EAP||HH HHA VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||57.88||36.46|20.26
5710001|EAP||HH HHA VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||57.88||36.46|20.26
5710001|EAP||HH HHA VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|Self-pay|Self-pay|||||57.88|20.26|36.46|20.26
5710001|EAP||HH HHA VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||57.88||36.46|20.26
5710001|EAP||HH HHA VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||57.88||36.46|20.26
5710001|EAP||HH HHA VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||57.88|0|36.46|20.26
5710001|EAP||HH HHA VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||57.88||36.46|20.26
5710001|EAP||HH HHA VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||57.88||36.46|20.26
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AARP [1000]|AARP [100000]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AETNA [1015]|AETNA [101529]|43.39||||43.39|19.13|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|43.39||||43.39|12.87|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS [1155]|BCBS UTHCT [115568]|43.39||||43.39|20.39|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|43.39||||43.39|21.7|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|43.39||||43.39|21.7|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|43.39||||43.39|27.34|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|43.39||||43.39|12.87|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA GWH [126023]|43.39||||43.39|23.86|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|43.39||||43.39|29.94|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|43.39||||43.39|21.7|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|43.39||||43.39|19.13|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|43.39||||43.39|12.87|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|43.39||||43.39|19.13|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|43.39||||43.39|12.87|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|43.39||||43.39|12.87|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|43.39||||43.39|29.94|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|43.39||||43.39|12.87|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|Self-pay|Self-pay|43.39||||43.39|15.19|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|43.39||||43.39|12.87|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|43.39||||43.39|12.87|29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|43.39||||43.39||29.94|12.87
5750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/GRAM TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|43.39||||43.39||29.94|12.87
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|AARP [1000]|AARP [100000]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|AETNA [1015]|AETNA [101529]|279.75||||279.75|123.37|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|279.75||||279.75|82.95|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|BCBS [1155]|BCBS UTHCT [115568]|279.75||||279.75|131.48|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|279.75||||279.75|139.88|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|279.75||||279.75|139.88|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|279.75||||279.75|176.24|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|279.75||||279.75|82.95|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|CIGNA [1260]|CIGNA GWH [126023]|279.75||||279.75|153.86|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|279.75||||279.75|193.03|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|279.75||||279.75|139.88|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|279.75||||279.75|123.37|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|279.75||||279.75|82.95|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|279.75||||279.75|123.37|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|279.75||||279.75|82.95|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|279.75||||279.75|82.95|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|279.75||||279.75|193.03|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|279.75||||279.75|82.95|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|Self-pay|Self-pay|279.75||||279.75|97.91|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|279.75||||279.75|82.95|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|279.75||||279.75|82.95|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|480 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|279.75||||279.75||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|2.61||||2.61|1.15|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.61||||2.61|0.77|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|2.61||||2.61|1.23|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.61||||2.61|1.31|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.61||||2.61|1.31|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.61||||2.61|1.64|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.61||||2.61|0.77|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|2.61||||2.61|1.44|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.61||||2.61|1.8|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.61||||2.61|1.31|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.61||||2.61|1.15|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.61||||2.61|0.77|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.61||||2.61|1.15|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.61||||2.61|0.77|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.61||||2.61|0.77|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.61||||2.61|1.8|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.61||||2.61|0.77|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|2.61||||2.61|0.91|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.61||||2.61|0.77|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.61||||2.61|0.77|193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.61||||2.61||193.03|0.77
5751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN 100,000 UNIT/ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.61||||2.61||193.03|0.77
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|277.61||||277.61|122.43|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|277.61||||277.61|82.31|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BCBS UTHCT [115568]|277.61||||277.61|130.48|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|277.61||||277.61|138.81|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|277.61||||277.61|138.81|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|277.61||||277.61|174.89|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|277.61||||277.61|82.31|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA GWH [126023]|277.61||||277.61|152.69|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|277.61||||277.61|191.55|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|277.61||||277.61|138.81|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|277.61||||277.61|122.43|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|277.61||||277.61|82.31|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|277.61||||277.61|122.43|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|277.61||||277.61|82.31|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|277.61||||277.61|82.31|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|277.61||||277.61|191.55|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|277.61||||277.61|82.31|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|277.61||||277.61|97.16|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|277.61||||277.61|82.31|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|277.61||||277.61|82.31|191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|277.61||||277.61||191.55|82.31
5754|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NYSTATIN-TRIAMCINOLONE 100,000 UNIT/G-0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|277.61||||277.61||191.55|82.31
5800001|EAP||HH INITIAL RT VISIT|1|AARP [1000]|AARP [100000]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||150||94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|AETNA [1015]|AETNA [101529]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||150||94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||150||94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||150|70.5|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||150|75|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||150|75|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||150|94.5|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||150||94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||150||94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||150||94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|Self-pay|Self-pay|||||150|52.5|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||150||94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||150||94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||150|0|94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||150||94.5|52.5
5800001|EAP||HH INITIAL RT VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|AARP [1000]|AARP [100000]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|AETNA [1015]|AETNA [101529]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BCBS UTHCT [115568]|||||150|70.5|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|||||150|75|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|||||150|75|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|||||150|94.5|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|CIGNA [1260]|CIGNA GWH [126023]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|Self-pay|Self-pay|||||150|52.5|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|||||150|0|94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|||||150||94.5|52.5
5810001|EAP||HH RT ROUTINE VISIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|||||150||94.5|52.5
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|48.36||||48.36|14.67|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48.36||||48.36||33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|48.36||||48.36|15.62|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48.36||||48.36|14.34|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48.36||||48.36||33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48.36||||48.36||33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|48.36||||48.36|22.73|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48.36||||48.36|0|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48.36||||48.36|24.18|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48.36||||48.36|30.47|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48.36||||48.36|14.34|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48.36||||48.36||33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|48.36||||48.36|26.6|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|48.36||||48.36|33.37|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|48.36||||48.36|8.54|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48.36||||48.36||33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48.36||||48.36|15.62|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48.36||||48.36|14.34|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48.36||||48.36||33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48.36||||48.36|15.62|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48.36||||48.36|14.34|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|48.36||||48.36|14.34|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|48.36||||48.36|33.37|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48.36||||48.36|14.34|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|48.36||||48.36|16.93|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|48.36||||48.36|14.34|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48.36||||48.36|14.34|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48.36||||48.36|14.67|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|48.36||||48.36||33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|48.36||||48.36||33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48.36||||48.36|14.67|33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48.36||||48.36||33.37|8.54
5886|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ORPHENADRINE CITRATE 30 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48.36||||48.36||33.37|8.54
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.76||||3.76|1.66|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.76||||3.76|1.11|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|3.76||||3.76|1.77|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.76||||3.76|1.88|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.76||||3.76|1.88|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.76||||3.76|2.37|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.76||||3.76|1.11|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|3.76||||3.76|2.07|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.76||||3.76|2.59|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.76||||3.76|1.88|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.76||||3.76|1.66|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.76||||3.76|1.11|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.76||||3.76|1.66|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.76||||3.76|1.11|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.76||||3.76|1.11|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.76||||3.76|2.59|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.76||||3.76|1.11|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|Self-pay|Self-pay|3.76||||3.76|1.32|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.76||||3.76|1.11|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.76||||3.76|1.11|2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.76||||3.76||2.59|1.11
5931|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXAZEPAM 15 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.76||||3.76||2.59|1.11
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.42||||1.42|0.63|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.42||||1.42|0.42|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.42||||1.42|0.67|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.42||||1.42|0.71|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.42||||1.42|0.71|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.42||||1.42|0.89|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.42||||1.42|0.42|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.42||||1.42|0.78|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.42||||1.42|0.98|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.42||||1.42|0.71|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.42||||1.42|0.63|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.42||||1.42|0.42|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.42||||1.42|0.63|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.42||||1.42|0.42|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.42||||1.42|0.42|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.42||||1.42|0.98|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.42||||1.42|0.42|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.42||||1.42|0.5|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.42||||1.42|0.42|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.42||||1.42|0.42|0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.42||||1.42||0.98|0.42
5938|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYBUTYNIN CHLORIDE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.42||||1.42||0.98|0.42
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.22||||1.22|0.54|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.22||||1.22|0.36|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.22||||1.22|0.57|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.22||||1.22|0.61|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.22||||1.22|0.61|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.22||||1.22|0.77|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.22||||1.22|0.36|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.22||||1.22|0.67|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.22||||1.22|0.84|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.22||||1.22|0.61|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.22||||1.22|0.54|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.22||||1.22|0.36|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.22||||1.22|0.54|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.22||||1.22|0.36|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.22||||1.22|0.36|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.22||||1.22|0.84|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.22||||1.22|0.36|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|Self-pay|Self-pay|1.22||||1.22|0.43|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.22||||1.22|0.36|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.22||||1.22|0.36|0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.22||||1.22||0.84|0.36
5940|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.22||||1.22||0.84|0.36
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AARP [1000]|AARP [100000]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AETNA [1015]|AETNA [101529]|4.93||||4.93|2.17|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BCBS UTHCT [115568]|4.93||||4.93|2.32|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.93||||4.93|2.47|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.93||||4.93|2.47|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.93||||4.93|3.11|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|CIGNA [1260]|CIGNA GWH [126023]|4.93||||4.93|2.71|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.93||||4.93|3.4|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.93||||4.93|2.47|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.93||||4.93|2.17|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.93||||4.93|2.17|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.93||||4.93|3.4|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|Self-pay|Self-pay|4.93||||4.93|1.73|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AARP [1000]|AARP [100000]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AETNA [1015]|AETNA [101529]|4.93||||4.93|2.17|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS [1155]|BCBS UTHCT [115568]|4.93||||4.93|2.32|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.93||||4.93|2.47|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.93||||4.93|2.47|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.93||||4.93|3.11|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|CIGNA [1260]|CIGNA GWH [126023]|4.93||||4.93|2.71|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.93||||4.93|3.4|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.93||||4.93|2.47|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.93||||4.93|2.17|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.93||||4.93|2.17|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.93||||4.93|3.4|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|Self-pay|Self-pay|4.93||||4.93|1.73|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.93||||4.93|1.46|3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.93||||4.93||3.4|1.46
5943|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OXYMETAZOLINE 0.05 % NASAL SPRAY|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.93||||4.93||3.4|1.46
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|AARP [1000]|AARP [100000]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|AETNA [1015]|AETNA [101529]|3.35||||3.35|1.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.35||||3.35|0.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|BCBS [1155]|BCBS UTHCT [115568]|3.35||||3.35|1.57|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.35||||3.35|0|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.35||||3.35|1.68|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.35||||3.35|2.11|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.35||||3.35|0.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|CIGNA [1260]|CIGNA GWH [126023]|3.35||||3.35|1.84|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.35||||3.35|2.31|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.35||||3.35|1.68|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.35||||3.35|1.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.35||||3.35|0.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.35||||3.35|1.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.35||||3.35|0.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.35||||3.35|0.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.35||||3.35|2.31|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.35||||3.35|0.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|Self-pay|Self-pay|3.35||||3.35|1.17|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.35||||3.35|0.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.35||||3.35|0.99|2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.35||||3.35||2.31|0.99
5944|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXYTOCIN 10 UNIT/ML INJECTION SOLUTION|0.3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.35||||3.35||2.31|0.99
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|128.38||||128.38|56.62|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|128.38||||128.38|38.06|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|128.38||||128.38|60.34|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|128.38||||128.38|64.19|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|128.38||||128.38|64.19|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|128.38||||128.38|80.88|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|128.38||||128.38|38.06|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|128.38||||128.38|70.61|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|128.38||||128.38|88.58|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|128.38||||128.38|64.19|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|128.38||||128.38|56.62|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|128.38||||128.38|38.06|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|128.38||||128.38|56.62|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|128.38||||128.38|38.06|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|128.38||||128.38|38.06|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|128.38||||128.38|88.58|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|128.38||||128.38|38.06|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|128.38||||128.38|44.93|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|128.38||||128.38|38.06|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|128.38||||128.38|38.06|88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|128.38||||128.38||88.58|38.06
6030|ERX|0250 - PHARMACY-GENERAL|PAPAVERINE 30 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|128.38||||128.38||88.58|38.06
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AARP [1000]|AARP [100000]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AETNA [1015]|AETNA [101529]|108.5||||108.5|23.98|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.5||||108.5|32.17|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BCBS UTHCT [115568]|108.5||||108.5|51|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.5||||108.5|0|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.5||||108.5|54.25|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.5||||108.5|68.36|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.5||||108.5|32.17|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA [1260]|CIGNA GWH [126023]|108.5||||108.5|59.68|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|GROUP PENSION ADMIN [1450]|GPA [145000]|108.5||||108.5|74.87|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|HEALTHFIRST [2395]|HEALTHFIRST [239500]|108.5||||108.5|1.38|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.5||||108.5|23.98|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.5||||108.5|32.17|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.5||||108.5|23.98|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.5||||108.5|32.17|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|PENDING SSI [1616]|PENDING SSI RCA [161601]|108.5||||108.5|32.17|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|PHCS [1780]|PHCS MULTIPLAN [178000]|108.5||||108.5|74.87|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.5||||108.5|32.17|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|Self-pay|Self-pay|108.5||||108.5|37.97|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|108.5||||108.5|32.17|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.5||||108.5|32.17|74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.5||||108.5||74.87|1.38
6086|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PENICILLIN G POTASSIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.5||||108.5||74.87|1.38
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AARP [1000]|AARP [100000]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AETNA [1015]|AETNA [101529]|142.85||||142.85|63|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|142.85||||142.85|42.36|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BCBS UTHCT [115568]|142.85||||142.85|67.14|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|142.85||||142.85|71.43|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|142.85||||142.85|71.43|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|142.85||||142.85|90|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|142.85||||142.85|42.36|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|CIGNA [1260]|CIGNA GWH [126023]|142.85||||142.85|78.57|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|GROUP PENSION ADMIN [1450]|GPA [145000]|142.85||||142.85|98.57|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|HEALTHFIRST [2395]|HEALTHFIRST [239500]|142.85||||142.85|71.43|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MAILHANDLERS [1595]|MAILHANDLERS [159500]|142.85||||142.85|63|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|142.85||||142.85|42.36|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|142.85||||142.85|63|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|142.85||||142.85|42.36|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|PENDING SSI [1616]|PENDING SSI RCA [161601]|142.85||||142.85|42.36|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|PHCS [1780]|PHCS MULTIPLAN [178000]|142.85||||142.85|98.57|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|142.85||||142.85|42.36|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|Self-pay|Self-pay|142.85||||142.85|50|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|142.85||||142.85|42.36|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|142.85||||142.85|42.36|98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UMR [2035]|UMR UNITED HEALTHCARE [203502]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|142.85||||142.85||98.57|42.36
6087|ERX|0250 - PHARMACY-GENERAL|PENICILLIN G SODIUM 5 MILLION UNIT SOLUTION FOR INJECTION|5 Million Units|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|142.85||||142.85||98.57|42.36
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|0.92||||0.92|0.41|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.92||||0.92|0.27|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.92||||0.92|0.43|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.92||||0.92|0.46|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.92||||0.92|0.46|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.92||||0.92|0.58|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.92||||0.92|0.27|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.92||||0.92|0.51|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.92||||0.92|0.63|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.92||||0.92|0.46|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.92||||0.92|0.41|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.92||||0.92|0.27|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.92||||0.92|0.41|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.92||||0.92|0.27|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.92||||0.92|0.27|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.92||||0.92|0.63|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.92||||0.92|0.27|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|Self-pay|Self-pay|0.92||||0.92|0.32|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.92||||0.92|0.27|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.92||||0.92|0.27|0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.92||||0.92||0.63|0.27
6091|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 250 MG/5 ML ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.92||||0.92||0.63|0.27
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.9||||2.9|1.28|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.9||||2.9|0.86|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.9||||2.9|1.36|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.9||||2.9|1.45|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.9||||2.9|1.45|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.9||||2.9|1.83|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.9||||2.9|0.86|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.9||||2.9|1.6|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.9||||2.9|2|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.9||||2.9|1.45|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.9||||2.9|1.28|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.9||||2.9|0.86|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.9||||2.9|1.28|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.9||||2.9|0.86|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.9||||2.9|0.86|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.9||||2.9|2|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.9||||2.9|0.86|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|Self-pay|Self-pay|2.9||||2.9|1.01|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.9||||2.9|0.86|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.9||||2.9|0.86|2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.9||||2.9||2|0.86
6093|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PENICILLIN V POTASSIUM 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.9||||2.9||2|0.86
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001001|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001002|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001003|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001004|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001007|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001008|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001009|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001010|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001011|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001012|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001013|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001014|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001015|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001016|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001017|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001018|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001019|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001020|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001022|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61001023|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|AARP [1000]|AARP [100000]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|316.07|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|501.02|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|308.34|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|533|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|671.58|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|316.07|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|533|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|316.07|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|316.07|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|316.07|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|316.07|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|Self-pay|Self-pay|1066||||1066|373.1|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|316.07|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|316.07|880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||880|308.34
61008900|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||880|308.34
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|AARP [1000]|AARP [100000]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|666||||666|666|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|666||||666|197.47|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|666||||666|313.02|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|666||||666|283.42|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|666||||666|333|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|666||||666|419.58|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|666||||666|197.47|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|666||||666|650|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|666||||666|459.54|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|666||||666|333|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|666||||666|666|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|666||||666|197.47|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|666||||666|666|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|666||||666|197.47|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|666||||666|197.47|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|666||||666|459.54|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|666||||666|197.47|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|Self-pay|Self-pay|666||||666|233.1|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|666||||666|197.47|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|666||||666|197.47|666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|666||||666||666|197.47
61008901|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|666||||666||666|197.47
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|316.07|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|501.02|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|556.77|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|533|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|671.58|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|316.07|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|533|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|316.07|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|316.07|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|316.07|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|316.07|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|Self-pay|Self-pay|1066||||1066|373.1|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|316.07|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|316.07|880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||880|316.07
61008902|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA ABDOMEN W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||880|316.07
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|AARP [1000]|AARP [100000]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|AETNA [1015]|AETNA [101529]|517||||517|517|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|517||||517|153.29|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|BCBS [1155]|BCBS UTHCT [115568]|517||||517|242.99|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|517||||517|308.34|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|517||||517|258.5|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|517||||517|325.71|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|517||||517|153.29|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|CIGNA [1260]|CIGNA GWH [126023]|517||||517|517|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|517||||517|356.73|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|517||||517|223.19|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|517||||517|517|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|517||||517|153.29|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|517||||517|517|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|517||||517|153.29|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|517||||517|153.29|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|517||||517|356.73|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|517||||517|153.29|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|Self-pay|Self-pay|517||||517|180.95|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|517||||517|153.29|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|517||||517|153.29|517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|517||||517||517|153.29
61008903|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI W/CONTRAST BREAST UNILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|517||||517||517|153.29
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|AARP [1000]|AARP [100000]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|316.07|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|501.02|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|556.77|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|533|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|671.58|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|316.07|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|338.74|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|316.07|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|316.07|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|316.07|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|316.07|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|Self-pay|Self-pay|1066||||1066|373.1|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|316.07|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|316.07|880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||880|316.07
61008905|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST UNILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|AARP [1000]|AARP [100000]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|316.07|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|501.02|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|556.77|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|533|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|671.58|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|316.07|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|460.15|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|316.07|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|316.07|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|316.07|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|316.07|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|Self-pay|Self-pay|1066||||1066|373.1|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|316.07|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|316.07|880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||880|316.07
61008906|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST BILAT W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||880|316.07
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|AARP [1000]|AARP [100000]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|AETNA [1015]|AETNA [101529]|2800||||2800|880|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2800||||2800|830.2|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|2800||||2800|1316|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2800||||2800|556.77|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2800||||2800|1400|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2800||||2800|1764|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2800||||2800|830.2|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|2800||||2800|650|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2800||||2800|1932|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2800||||2800|337.08|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2800||||2800|880|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2800||||2800|830.2|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2800||||2800|880|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2800||||2800|830.2|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2800||||2800|830.2|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2800||||2800|1932|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2800||||2800|830.2|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|Self-pay|Self-pay|2800||||2800|980|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2800||||2800|830.2|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2800||||2800|830.2|1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2800||||2800||1932|337.08
61008908|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC BREAST W/ & W/O CONTRAST BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2800||||2800||1932|337.08
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|AARP [1000]|AARP [100000]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|316.07|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|501.02|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|308.34|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|533|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|671.58|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|316.07|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|533|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|316.07|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|316.07|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|316.07|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|316.07|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|Self-pay|Self-pay|1066||||1066|373.1|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|316.07|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|316.07|880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||880|308.34
61008909|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||880|308.34
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|AARP [1000]|AARP [100000]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|666||||666|666|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|666||||666|197.47|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|666||||666|313.02|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|666||||666|283.42|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|666||||666|333|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|666||||666|419.58|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|666||||666|197.47|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|666||||666|650|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|666||||666|459.54|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|666||||666|333|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|666||||666|666|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|666||||666|197.47|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|666||||666|666|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|666||||666|197.47|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|666||||666|197.47|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|666||||666|459.54|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|666||||666|197.47|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|Self-pay|Self-pay|666||||666|233.1|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|666||||666|197.47|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|666||||666|197.47|666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|666||||666||666|197.47
61008910|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|666||||666||666|197.47
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|316.07|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|501.02|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|556.77|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|533|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|671.58|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|316.07|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|533|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|316.07|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|316.07|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|316.07|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|316.07|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|Self-pay|Self-pay|1066||||1066|373.1|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|316.07|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|316.07|880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||880|316.07
61008911|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA CHEST W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||880|316.07
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|AARP [1000]|AARP [100000]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|666||||666|666|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|666||||666|197.47|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|666||||666|313.02|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|666||||666|283.42|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|666||||666|333|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|666||||666|419.58|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|666||||666|197.47|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|666||||666|650|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|666||||666|459.54|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|666||||666|333|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|666||||666|666|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|666||||666|197.47|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|666||||666|666|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|666||||666|197.47|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|666||||666|197.47|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|666||||666|459.54|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|666||||666|197.47|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|Self-pay|Self-pay|666||||666|233.1|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|666||||666|197.47|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|666||||666|197.47|666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|666||||666||666|197.47
61008913|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWER EXT W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|666||||666||666|197.47
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|AARP [1000]|AARP [100000]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|AETNA [1015]|AETNA [101529]|2067||||2067|880|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2067||||2067|612.87|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|BCBS [1155]|BCBS UTHCT [115568]|2067||||2067|971.49|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2067||||2067|556.77|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2067||||2067|1033.5|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2067||||2067|1302.21|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2067||||2067|612.87|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|CIGNA [1260]|CIGNA GWH [126023]|2067||||2067|650|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2067||||2067|1426.23|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2067||||2067|1033.5|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2067||||2067|880|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2067||||2067|612.87|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2067||||2067|880|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2067||||2067|612.87|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2067||||2067|612.87|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2067||||2067|1426.23|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2067||||2067|612.87|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|Self-pay|Self-pay|2067||||2067|723.45|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2067||||2067|612.87|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2067||||2067|612.87|1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2067||||2067||1426.23|556.77
61008914|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA LOWR EXT W/ & W/O CONT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2067||||2067||1426.23|556.77
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|AARP [1000]|AARP [100000]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|666||||666|666|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|666||||666|197.47|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|666||||666|313.02|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|666||||666|283.42|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|666||||666|333|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|666||||666|419.58|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|666||||666|197.47|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|666||||666|650|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|666||||666|459.54|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|666||||666|333|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|666||||666|666|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|666||||666|197.47|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|666||||666|666|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|666||||666|197.47|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|666||||666|197.47|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|666||||666|459.54|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|666||||666|197.47|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|Self-pay|Self-pay|666||||666|233.1|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|666||||666|197.47|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|666||||666|197.47|666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|666||||666||666|197.47
61008919|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|666||||666||666|197.47
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|316.07|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|501.02|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|556.77|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|533|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|671.58|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|316.07|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|533|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|316.07|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|316.07|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|316.07|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|316.07|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|Self-pay|Self-pay|1066||||1066|373.1|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|316.07|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|316.07|880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||880|316.07
61008920|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRA PELVIS W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||880|316.07
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|AARP [1000]|AARP [100000]|3559||||3559|940|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3559||||3559|210.77|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3559||||3559|880|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3559||||3559|232.31|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3559||||3559|208.68|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3559||||3559|208.68|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3559||||3559|862.5|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3559||||3559|283.42|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3559||||3559|1150|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3559||||3559|1150|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3559||||3559|232.31|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3559||||3559|208.68|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3559||||3559|650|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3559||||3559|2455.71|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3559||||3559|287.66|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3559||||3559|223.5|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3559||||3559|880|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3559||||3559|232.31|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3559||||3559|208.68|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3559||||3559|880|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3559||||3559|232.31|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3559||||3559|232.31|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3559||||3559|2455.71|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3559||||3559|232.31|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|Self-pay|Self-pay|3559||||3559|1245.65|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3559||||3559|232.31|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3559||||3559|232.31|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3559||||3559|940|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3559||||3559|208.68|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3559||||3559|208.68|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3559||||3559|940|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3559||||3559|208.68|2455.71|208.68
61070540|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3559||||3559|417.37|2455.71|208.68
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|AARP [1000]|AARP [100000]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|AETNA [1015]|AETNA [101529]|3650||||3650|880|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3650||||3650|304.39|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3650||||3650|862.5|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3650||||3650|556.77|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3650||||3650|1150|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3650||||3650|1150|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3650||||3650|304.39|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3650||||3650|650|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3650||||3650|2518.5|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3650||||3650|460.15|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3650||||3650|880|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3650||||3650|304.39|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3650||||3650|880|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3650||||3650|304.39|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3650||||3650|304.39|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3650||||3650|2518.5|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3650||||3650|304.39|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|Self-pay|Self-pay|3650||||3650|1277.5|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3650||||3650|304.39|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3650||||3650|304.39|2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3650||||3650||2518.5|304.39
61070542|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/ CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3650||||3650||2518.5|304.39
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|AARP [1000]|AARP [100000]|3748||||3748|940|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3748||||3748|337.15|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|AETNA [1015]|AETNA [101529]|3748||||3748|880|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3748||||3748|382.25|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3748||||3748|333.81|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3748||||3748|333.81|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3748||||3748|862.5|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3748||||3748|556.77|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3748||||3748|1150|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3748||||3748|1150|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3748||||3748|382.25|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3748||||3748|333.81|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3748||||3748|650|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3748||||3748|2586.12|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3748||||3748|460.15|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3748||||3748|357.52|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3748||||3748|880|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3748||||3748|382.25|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3748||||3748|333.81|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3748||||3748|880|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3748||||3748|382.25|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3748||||3748|382.25|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3748||||3748|2586.12|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3748||||3748|382.25|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|Self-pay|Self-pay|3748||||3748|1311.8|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3748||||3748|382.25|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3748||||3748|382.25|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3748||||3748|940|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3748||||3748|333.81|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3748||||3748|333.81|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3748||||3748|940|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3748||||3748|333.81|2586.12|333.81
61070543|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ORBIT/FACE/NECK W/WO CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3748||||3748|667.63|2586.12|333.81
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|AARP [1000]|AARP [100000]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3050||||3050|880|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3050||||3050|232.31|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3050||||3050|862.5|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3050||||3050|283.42|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3050||||3050|1150|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3050||||3050|1150|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3050||||3050|232.31|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3050||||3050|650|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3050||||3050|2104.5|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3050||||3050|287.66|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3050||||3050|880|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3050||||3050|232.31|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3050||||3050|880|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3050||||3050|232.31|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3050||||3050|232.31|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3050||||3050|2104.5|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3050||||3050|232.31|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|Self-pay|Self-pay|3050||||3050|1067.5|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3050||||3050|232.31|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3050||||3050|232.31|2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3050||||3050||2104.5|232.31
61071550|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3050||||3050||2104.5|232.31
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|AARP [1000]|AARP [100000]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|AETNA [1015]|AETNA [101529]|3500||||3500|880|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3500||||3500|432.7|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3500||||3500|862.5|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3500||||3500|831.89|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3500||||3500|1150|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3500||||3500|1150|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3500||||3500|432.7|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3500||||3500|650|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3500||||3500|2415|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3500||||3500|893.98|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3500||||3500|880|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3500||||3500|432.7|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3500||||3500|880|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3500||||3500|432.7|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3500||||3500|432.7|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3500||||3500|2415|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3500||||3500|432.7|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|Self-pay|Self-pay|3500||||3500|1225|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3500||||3500|432.7|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3500||||3500|432.7|2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3500||||3500||2415|432.7
61071551|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST WITH CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3500||||3500||2415|432.7
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4966||||4966|880|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4966||||4966|456.37|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|4966||||4966|862.5|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4966||||4966|556.77|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4966||||4966|1150|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4966||||4966|1150|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4966||||4966|456.37|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|4966||||4966|650|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4966||||4966|3426.54|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4966||||4966|460.15|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4966||||4966|880|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4966||||4966|456.37|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4966||||4966|880|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4966||||4966|456.37|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4966||||4966|456.37|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4966||||4966|3426.54|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4966||||4966|456.37|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|Self-pay|Self-pay|4966||||4966|1738.1|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4966||||4966|456.37|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4966||||4966|456.37|3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4966||||4966||3426.54|456.37
61071552|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI CHEST W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4966||||4966||3426.54|456.37
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|AARP [1000]|AARP [100000]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|AETNA [1015]|AETNA [101529]|3200||||3200|880|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3200||||3200|329.13|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3200||||3200|862.5|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3200||||3200|556.77|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3200||||3200|1150|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3200||||3200|1150|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3200||||3200|329.13|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3200||||3200|650|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3200||||3200|2208|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3200||||3200|460.15|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3200||||3200|880|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3200||||3200|329.13|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3200||||3200|880|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3200||||3200|329.13|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3200||||3200|329.13|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3200||||3200|2208|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3200||||3200|329.13|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|Self-pay|Self-pay|3200||||3200|1120|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3200||||3200|329.13|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3200||||3200|329.13|2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3200||||3200||2208|329.13
61072196|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS WITH CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3200||||3200||2208|329.13
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|4433||||4433|940|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4433||||4433|337.15|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4433||||4433|880|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4433||||4433|403.3|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4433||||4433|333.81|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4433||||4433|333.81|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|4433||||4433|862.5|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4433||||4433|556.77|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4433||||4433|1150|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4433||||4433|1150|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4433||||4433|403.3|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4433||||4433|333.81|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|4433||||4433|650|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4433||||4433|3058.77|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4433||||4433|460.15|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4433||||4433|357.52|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4433||||4433|880|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4433||||4433|403.3|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4433||||4433|333.81|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4433||||4433|880|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4433||||4433|403.3|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4433||||4433|403.3|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4433||||4433|3058.77|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4433||||4433|403.3|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|Self-pay|Self-pay|4433||||4433|1551.55|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4433||||4433|403.3|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4433||||4433|403.3|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4433||||4433|940|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4433||||4433|333.81|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4433||||4433|333.81|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4433||||4433|940|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4433||||4433|333.81|3058.77|333.81
61072197|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI PELVIS W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4433||||4433|667.63|3058.77|333.81
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|AARP [1000]|AARP [100000]|2657||||2657|940|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2657||||2657|210.77|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2657||||2657|880|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2657||||2657|232.31|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2657||||2657|208.68|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2657||||2657|208.68|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2657||||2657|862.5|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2657||||2657|283.42|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2657||||2657|1150|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2657||||2657|1150|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2657||||2657|232.31|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2657||||2657|208.68|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2657||||2657|650|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2657||||2657|1833.33|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2657||||2657|287.66|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2657||||2657|223.5|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2657||||2657|880|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2657||||2657|232.31|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2657||||2657|208.68|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2657||||2657|880|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2657||||2657|232.31|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2657||||2657|232.31|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2657||||2657|1833.33|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2657||||2657|232.31|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|Self-pay|Self-pay|2657||||2657|929.95|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2657||||2657|232.31|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2657||||2657|232.31|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2657||||2657|940|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2657||||2657|208.68|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2657||||2657|208.68|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2657||||2657|940|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2657||||2657|208.68|1833.33|208.68
61073218|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2657||||2657|417.37|1833.33|208.68
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|AARP [1000]|AARP [100000]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|381.58|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|862.5|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|556.77|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|1066|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|1066|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|381.58|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|460.15|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|381.58|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|381.58|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|381.58|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|381.58|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|Self-pay|Self-pay|1066||||1066|373.1|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|381.58|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|381.58|1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||1066|373.1
61073219|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXTR W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||1066|373.1
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AARP [1000]|AARP [100000]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AETNA [1015]|AETNA [101529]|3609||||3609|880|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3609||||3609|456.37|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS [1155]|BCBS UTHCT [115568]|3609||||3609|862.5|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3609||||3609|556.77|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3609||||3609|1150|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3609||||3609|1150|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3609||||3609|456.37|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|CIGNA [1260]|CIGNA GWH [126023]|3609||||3609|650|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3609||||3609|2490.21|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3609||||3609|460.15|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3609||||3609|880|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3609||||3609|456.37|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3609||||3609|880|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3609||||3609|456.37|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3609||||3609|456.37|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3609||||3609|2490.21|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3609||||3609|456.37|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|Self-pay|Self-pay|3609||||3609|1263.15|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3609||||3609|456.37|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3609||||3609|456.37|2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3609||||3609||2490.21|456.37
61073220|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT W W/O CONT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3609||||3609||2490.21|456.37
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|AARP [1000]|AARP [100000]|2878||||2878|940|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2878||||2878|210.77|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2878||||2878|880|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2878||||2878|224.88|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2878||||2878|208.68|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2878||||2878|208.68|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2878||||2878|862.5|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2878||||2878|283.42|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2878||||2878|1150|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2878||||2878|1150|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2878||||2878|224.88|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2878||||2878|208.68|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2878||||2878|650|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2878||||2878|1985.82|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2878||||2878|287.66|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2878||||2878|223.5|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2878||||2878|880|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2878||||2878|224.88|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2878||||2878|208.68|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2878||||2878|880|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2878||||2878|224.88|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2878||||2878|224.88|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2878||||2878|1985.82|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2878||||2878|224.88|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|Self-pay|Self-pay|2878||||2878|1007.3|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2878||||2878|224.88|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2878||||2878|224.88|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2878||||2878|940|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2878||||2878|208.68|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2878||||2878|208.68|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2878||||2878|940|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2878||||2878|208.68|1985.82|208.68
61073221|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2878||||2878|417.37|1985.82|208.68
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|AARP [1000]|AARP [100000]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|AETNA [1015]|AETNA [101529]|3229||||3229|880|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3229||||3229|359.19|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3229||||3229|862.5|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3229||||3229|831.89|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3229||||3229|1150|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3229||||3229|1150|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3229||||3229|359.19|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3229||||3229|650|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3229||||3229|2228.01|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3229||||3229|893.98|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3229||||3229|880|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3229||||3229|359.19|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3229||||3229|880|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3229||||3229|359.19|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3229||||3229|359.19|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3229||||3229|2228.01|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3229||||3229|359.19|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|Self-pay|Self-pay|3229||||3229|1130.15|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3229||||3229|359.19|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3229||||3229|359.19|2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3229||||3229||2228.01|359.19
61073222|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3229||||3229||2228.01|359.19
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AARP [1000]|AARP [100000]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3890||||3890|880|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3890||||3890|445.4|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3890||||3890|862.5|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3890||||3890|556.77|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3890||||3890|1150|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3890||||3890|1150|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3890||||3890|445.4|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3890||||3890|650|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3890||||3890|2684.1|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3890||||3890|460.15|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3890||||3890|880|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3890||||3890|445.4|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3890||||3890|880|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3890||||3890|445.4|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3890||||3890|445.4|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3890||||3890|2684.1|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3890||||3890|445.4|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|Self-pay|Self-pay|3890||||3890|1361.5|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3890||||3890|445.4|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3890||||3890|445.4|2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3890||||3890||2684.1|445.4
61073223|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC UPPER EXT JOINT W/&W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3890||||3890||2684.1|445.4
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AARP [1000]|AARP [100000]|3056||||3056|940|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3056||||3056|210.77|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3056||||3056|880|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3056||||3056|232.31|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3056||||3056|208.68|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3056||||3056|208.68|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3056||||3056|862.5|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3056||||3056|283.42|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3056||||3056|1150|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3056||||3056|1150|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3056||||3056|232.31|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3056||||3056|208.68|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3056||||3056|650|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3056||||3056|2108.64|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3056||||3056|287.66|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3056||||3056|223.5|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3056||||3056|880|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3056||||3056|232.31|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3056||||3056|208.68|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3056||||3056|880|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3056||||3056|232.31|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3056||||3056|232.31|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3056||||3056|2108.64|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3056||||3056|232.31|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|Self-pay|Self-pay|3056||||3056|1069.6|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3056||||3056|232.31|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3056||||3056|232.31|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3056||||3056|940|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3056||||3056|208.68|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3056||||3056|208.68|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3056||||3056|940|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3056||||3056|208.68|2108.64|208.68
61073718|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXTR W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3056||||3056|417.37|2108.64|208.68
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|AARP [1000]|AARP [100000]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|252.74|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|862.5|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|308.34|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|1066|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|1066|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|252.74|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|460.15|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|252.74|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|252.74|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|252.74|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|252.74|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|Self-pay|Self-pay|1066||||1066|373.1|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|252.74|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|252.74|1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||1066|252.74
61073719|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW EXT W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||1066|252.74
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|3890||||3890|940|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3890||||3890|337.15|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3890||||3890|880|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3890||||3890|402.63|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3890||||3890|333.81|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3890||||3890|333.81|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3890||||3890|862.5|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3890||||3890|556.77|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3890||||3890|1150|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3890||||3890|1150|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3890||||3890|402.63|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3890||||3890|333.81|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3890||||3890|650|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3890||||3890|2684.1|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3890||||3890|460.15|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3890||||3890|357.52|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3890||||3890|880|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3890||||3890|402.63|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3890||||3890|333.81|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3890||||3890|880|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3890||||3890|402.63|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3890||||3890|402.63|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3890||||3890|2684.1|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3890||||3890|402.63|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|Self-pay|Self-pay|3890||||3890|1361.5|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3890||||3890|402.63|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3890||||3890|402.63|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3890||||3890|940|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3890||||3890|333.81|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3890||||3890|333.81|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3890||||3890|940|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3890||||3890|333.81|2684.1|333.81
61073720|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC LOWER EXTREMITY W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3890||||3890|667.63|2684.1|333.81
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|AARP [1000]|AARP [100000]|3010||||3010|940|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3010||||3010|210.77|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3010||||3010|880|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3010||||3010|224.88|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3010||||3010|208.68|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3010||||3010|208.68|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3010||||3010|862.5|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3010||||3010|283.42|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3010||||3010|1150|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3010||||3010|1150|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3010||||3010|224.88|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3010||||3010|208.68|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3010||||3010|650|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3010||||3010|2076.9|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3010||||3010|287.66|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3010||||3010|223.5|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3010||||3010|880|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3010||||3010|224.88|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3010||||3010|208.68|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3010||||3010|880|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3010||||3010|224.88|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3010||||3010|224.88|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3010||||3010|2076.9|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3010||||3010|224.88|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|Self-pay|Self-pay|3010||||3010|1053.5|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3010||||3010|224.88|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3010||||3010|224.88|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3010||||3010|940|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3010||||3010|208.68|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3010||||3010|208.68|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3010||||3010|940|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3010||||3010|208.68|2076.9|208.68
61073721|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3010||||3010|417.37|2076.9|208.68
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|AARP [1000]|AARP [100000]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|AETNA [1015]|AETNA [101529]|3500||||3500|880|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3500||||3500|361.53|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3500||||3500|862.5|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3500||||3500|831.89|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3500||||3500|1150|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3500||||3500|1150|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3500||||3500|361.53|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3500||||3500|650|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3500||||3500|2415|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3500||||3500|893.98|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3500||||3500|880|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3500||||3500|361.53|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3500||||3500|880|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3500||||3500|361.53|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3500||||3500|361.53|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3500||||3500|2415|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3500||||3500|361.53|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|Self-pay|Self-pay|3500||||3500|1225|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3500||||3500|361.53|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3500||||3500|361.53|2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3500||||3500||2415|361.53
61073722|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC Joint LOWER EXTREMITY W/ CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3500||||3500||2415|361.53
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|AARP [1000]|AARP [100000]|4163||||4163|940|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4163||||4163|337.15|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4163||||4163|880|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4163||||4163|444.73|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4163||||4163|333.81|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4163||||4163|333.81|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|4163||||4163|862.5|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4163||||4163|556.77|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4163||||4163|1150|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4163||||4163|1150|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4163||||4163|444.73|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4163||||4163|333.81|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|4163||||4163|650|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4163||||4163|2872.47|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4163||||4163|460.15|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4163||||4163|357.52|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4163||||4163|880|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4163||||4163|444.73|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4163||||4163|333.81|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4163||||4163|880|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4163||||4163|444.73|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4163||||4163|444.73|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4163||||4163|2872.47|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4163||||4163|444.73|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|Self-pay|Self-pay|4163||||4163|1457.05|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4163||||4163|444.73|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4163||||4163|444.73|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4163||||4163|940|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4163||||4163|333.81|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4163||||4163|333.81|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4163||||4163|940|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4163||||4163|333.81|2872.47|333.81
61073723|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI LOW JOINT W&W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4163||||4163|667.63|2872.47|333.81
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|AARP [1000]|AARP [100000]|3246||||3246|940|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3246||||3246|210.77|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3246||||3246|880|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3246||||3246|232.31|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3246||||3246|208.68|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3246||||3246|208.68|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3246||||3246|862.5|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3246||||3246|283.42|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3246||||3246|1150|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3246||||3246|1150|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3246||||3246|232.31|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3246||||3246|208.68|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3246||||3246|650|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3246||||3246|2239.74|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3246||||3246|287.66|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3246||||3246|223.5|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3246||||3246|880|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3246||||3246|232.31|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3246||||3246|208.68|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3246||||3246|880|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3246||||3246|232.31|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3246||||3246|232.31|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3246||||3246|2239.74|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3246||||3246|232.31|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|Self-pay|Self-pay|3246||||3246|1136.1|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3246||||3246|232.31|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3246||||3246|232.31|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3246||||3246|940|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3246||||3246|208.68|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3246||||3246|208.68|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3246||||3246|940|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3246||||3246|208.68|2239.74|208.68
61074181|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3246||||3246|417.37|2239.74|208.68
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|AARP [1000]|AARP [100000]|3500||||3500|940|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3500||||3500|337.15|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|AETNA [1015]|AETNA [101529]|3500||||3500|880|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3500||||3500|362.54|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3500||||3500|333.81|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3500||||3500|333.81|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3500||||3500|862.5|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3500||||3500|556.77|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3500||||3500|1150|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3500||||3500|1150|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3500||||3500|362.54|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3500||||3500|333.81|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3500||||3500|650|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3500||||3500|2415|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3500||||3500|460.15|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3500||||3500|357.52|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3500||||3500|880|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3500||||3500|362.54|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3500||||3500|333.81|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3500||||3500|880|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3500||||3500|362.54|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3500||||3500|362.54|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3500||||3500|2415|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3500||||3500|362.54|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|Self-pay|Self-pay|3500||||3500|1225|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3500||||3500|362.54|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3500||||3500|362.54|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3500||||3500|940|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3500||||3500|333.81|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3500||||3500|333.81|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3500||||3500|940|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3500||||3500|333.81|2415|333.81
61074182|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W/ CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3500||||3500|667.63|2415|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|4262||||4262|940|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4262||||4262|337.15|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4262||||4262|880|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4262||||4262|404.3|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4262||||4262|333.81|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4262||||4262|333.81|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|4262||||4262|862.5|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4262||||4262|556.77|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4262||||4262|1150|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4262||||4262|1150|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4262||||4262|404.3|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4262||||4262|333.81|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|4262||||4262|650|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4262||||4262|2940.78|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4262||||4262|460.15|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4262||||4262|357.52|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4262||||4262|880|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4262||||4262|404.3|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4262||||4262|333.81|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4262||||4262|880|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4262||||4262|404.3|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4262||||4262|404.3|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4262||||4262|2940.78|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4262||||4262|404.3|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|Self-pay|Self-pay|4262||||4262|1491.7|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4262||||4262|404.3|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4262||||4262|404.3|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4262||||4262|940|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4262||||4262|333.81|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4262||||4262|333.81|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4262||||4262|940|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4262||||4262|333.81|2940.78|333.81
61074183|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC ABDOMEN W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4262||||4262|667.63|2940.78|333.81
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|AARP [1000]|AARP [100000]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|AETNA [1015]|AETNA [101529]|1652||||1652|880|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1652||||1652|489.82|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|BCBS [1155]|BCBS UTHCT [115568]|1652||||1652|862.5|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1652||||1652|469.81|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1652||||1652|1150|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1652||||1652|1150|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1652||||1652|489.82|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|CIGNA [1260]|CIGNA GWH [126023]|1652||||1652|650|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1652||||1652|1139.88|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1652||||1652|101.13|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1652||||1652|880|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1652||||1652|489.82|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1652||||1652|880|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1652||||1652|489.82|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1652||||1652|489.82|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1652||||1652|1139.88|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1652||||1652|489.82|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|Self-pay|Self-pay|1652||||1652|578.2|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1652||||1652|489.82|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1652||||1652|489.82|1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1652||||1652||1150|101.13
61076390|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR SPECTROSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1652||||1652||1150|101.13
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|AARP [1000]|AARP [100000]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|AETNA [1015]|AETNA [101529]|3187||||3187|880|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3187||||3187|944.95|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|BCBS [1155]|BCBS UTHCT [115568]|3187||||3187|862.5|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3187||||3187|392.74|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3187||||3187|1150|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3187||||3187|1150|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3187||||3187|944.95|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|CIGNA [1260]|CIGNA GWH [126023]|3187||||3187|650|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3187||||3187|2199.03|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3187||||3187|1593.5|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3187||||3187|880|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3187||||3187|944.95|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3187||||3187|880|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3187||||3187|944.95|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3187||||3187|944.95|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3187||||3187|2199.03|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3187||||3187|944.95|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|Self-pay|Self-pay|3187||||3187|1115.45|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3187||||3187|944.95|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3187||||3187|944.95|2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3187||||3187||2199.03|392.74
61077021|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MR GUIDANCE FOR NEEDLE PLACEMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3187||||3187||2199.03|392.74
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|AARP [1000]|AARP [100000]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|AETNA [1015]|AETNA [101529]|666||||666|666|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|666||||666|197.47|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|BCBS [1155]|BCBS UTHCT [115568]|666||||666|313.02|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|666||||666|281.28|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|666||||666|333|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|666||||666|419.58|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|666||||666|197.47|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|CIGNA [1260]|CIGNA GWH [126023]|666||||666|650|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|666||||666|459.54|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|666||||666|287.66|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|666||||666|666|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|666||||666|197.47|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|666||||666|666|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|666||||666|197.47|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|666||||666|197.47|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|666||||666|459.54|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|666||||666|197.47|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|Self-pay|Self-pay|666||||666|233.1|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|666||||666|197.47|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|666||||666|197.47|666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|666||||666||666|197.47
61077047|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC MRI BREAST W/O CONTRAST MATERIAL BILATERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|666||||666||666|197.47
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101001|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101002|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101003|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101004|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101007|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101008|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101009|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101010|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101011|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101012|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101013|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101014|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101015|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101016|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101017|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101018|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101019|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101020|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101021|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101022|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61101023|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|AARP [1000]|AARP [100000]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|AETNA [1015]|AETNA [101529]|67.43||||67.43|29.74|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|67.43||||67.43|19.99|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|BCBS [1155]|BCBS UTHCT [115568]|67.43||||67.43|31.69|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|67.43||||67.43|33.72|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|67.43||||67.43|33.72|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|67.43||||67.43|42.48|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|67.43||||67.43|19.99|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|CIGNA [1260]|CIGNA GWH [126023]|67.43||||67.43|37.09|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|67.43||||67.43|46.53|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|67.43||||67.43|33.72|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|67.43||||67.43|29.74|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|67.43||||67.43|19.99|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|67.43||||67.43|29.74|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|67.43||||67.43|19.99|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|67.43||||67.43|19.99|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|67.43||||67.43|46.53|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|67.43||||67.43|19.99|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|Self-pay|Self-pay|67.43||||67.43|23.6|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|67.43||||67.43|19.99|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|67.43||||67.43|19.99|46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|67.43||||67.43||46.53|19.99
6116|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PEPPERMINT OIL|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|67.43||||67.43||46.53|19.99
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AARP [1000]|AARP [100000]|2947||||2947|940|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2947||||2947|210.77|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2947||||2947|880|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2947||||2947|218.85|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2947||||2947|208.68|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2947||||2947|208.68|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2947||||2947|862.5|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2947||||2947|283.42|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2947||||2947|1150|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2947||||2947|1150|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2947||||2947|218.85|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2947||||2947|208.68|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2947||||2947|650|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2947||||2947|2033.43|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2947||||2947|287.66|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2947||||2947|223.5|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2947||||2947|880|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2947||||2947|218.85|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2947||||2947|208.68|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2947||||2947|880|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2947||||2947|218.85|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2947||||2947|218.85|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2947||||2947|2033.43|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2947||||2947|218.85|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|Self-pay|Self-pay|2947||||2947|1031.45|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2947||||2947|218.85|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2947||||2947|218.85|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2947||||2947|940|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2947||||2947|208.68|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2947||||2947|208.68|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2947||||2947|940|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2947||||2947|208.68|2033.43|208.68
61170551|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2947||||2947|417.37|2033.43|208.68
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AARP [1000]|AARP [100000]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AETNA [1015]|AETNA [101529]|3006||||3006|880|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3006||||3006|252.74|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3006||||3006|862.5|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3006||||3006|308.34|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3006||||3006|1150|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3006||||3006|1150|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3006||||3006|252.74|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3006||||3006|650|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3006||||3006|2074.14|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3006||||3006|460.15|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3006||||3006|880|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3006||||3006|252.74|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3006||||3006|880|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3006||||3006|252.74|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3006||||3006|252.74|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3006||||3006|2074.14|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3006||||3006|252.74|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|Self-pay|Self-pay|3006||||3006|1052.1|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3006||||3006|252.74|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3006||||3006|252.74|2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3006||||3006||2074.14|252.74
61170552|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3006||||3006||2074.14|252.74
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|4704||||4704|940|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4704||||4704|337.15|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4704||||4704|880|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4704||||4704|357.85|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4704||||4704|333.81|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4704||||4704|333.81|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|4704||||4704|862.5|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4704||||4704|556.77|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4704||||4704|1150|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4704||||4704|1150|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4704||||4704|357.85|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4704||||4704|333.81|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|4704||||4704|650|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4704||||4704|3245.76|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4704||||4704|460.15|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4704||||4704|357.52|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4704||||4704|880|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4704||||4704|357.85|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4704||||4704|333.81|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4704||||4704|880|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4704||||4704|357.85|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4704||||4704|357.85|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4704||||4704|3245.76|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4704||||4704|357.85|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|Self-pay|Self-pay|4704||||4704|1646.4|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4704||||4704|357.85|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4704||||4704|357.85|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4704||||4704|940|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4704||||4704|333.81|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4704||||4704|333.81|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4704||||4704|940|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4704||||4704|333.81|3245.76|333.81
61170553|EAP|0611 - MAGNETIC RESONANCE TECHNOLOGY-MRI-BRAIN/BRA|HC BRAIN W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4704||||4704|667.63|3245.76|333.81
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201001|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201002|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201003|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201004|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201007|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201008|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201009|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201010|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201011|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201012|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201013|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201014|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201015|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201016|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201017|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201018|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201019|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201020|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201021|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201022|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61201023|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|AARP [1000]|AARP [100000]|3112||||3112|940|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3112||||3112|210.77|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3112||||3112|880|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3112||||3112|212.84|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3112||||3112|208.68|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3112||||3112|208.68|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3112||||3112|862.5|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3112||||3112|283.42|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3112||||3112|1150|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3112||||3112|1150|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3112||||3112|212.84|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3112||||3112|208.68|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3112||||3112|650|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3112||||3112|2147.28|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3112||||3112|287.66|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3112||||3112|223.5|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3112||||3112|880|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3112||||3112|212.84|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3112||||3112|208.68|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3112||||3112|880|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3112||||3112|212.84|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3112||||3112|212.84|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3112||||3112|2147.28|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3112||||3112|212.84|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|Self-pay|Self-pay|3112||||3112|1089.2|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3112||||3112|212.84|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3112||||3112|212.84|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3112||||3112|940|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3112||||3112|208.68|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3112||||3112|208.68|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3112||||3112|940|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3112||||3112|208.68|2147.28|208.68
61272141|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3112||||3112|417.37|2147.28|208.68
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|AARP [1000]|AARP [100000]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|AETNA [1015]|AETNA [101529]|3326||||3326|880|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3326||||3326|309.08|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3326||||3326|862.5|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3326||||3326|556.77|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3326||||3326|1150|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3326||||3326|1150|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3326||||3326|309.08|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3326||||3326|650|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3326||||3326|2294.94|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3326||||3326|460.15|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3326||||3326|880|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3326||||3326|309.08|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3326||||3326|880|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3326||||3326|309.08|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3326||||3326|309.08|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3326||||3326|2294.94|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3326||||3326|309.08|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|Self-pay|Self-pay|3326||||3326|1164.1|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3326||||3326|309.08|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3326||||3326|309.08|2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3326||||3326||2294.94|309.08
61272142|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3326||||3326||2294.94|309.08
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|AARP [1000]|AARP [100000]|3243||||3243|940|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3243||||3243|210.77|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3243||||3243|880|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3243||||3243|213.18|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3243||||3243|208.68|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3243||||3243|208.68|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3243||||3243|862.5|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3243||||3243|283.42|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3243||||3243|1150|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3243||||3243|1150|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3243||||3243|213.18|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3243||||3243|208.68|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3243||||3243|650|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3243||||3243|2237.67|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3243||||3243|287.66|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3243||||3243|223.5|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3243||||3243|880|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3243||||3243|213.18|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3243||||3243|208.68|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3243||||3243|880|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3243||||3243|213.18|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3243||||3243|213.18|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3243||||3243|2237.67|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3243||||3243|213.18|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|Self-pay|Self-pay|3243||||3243|1135.05|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3243||||3243|213.18|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3243||||3243|213.18|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3243||||3243|940|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3243||||3243|208.68|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3243||||3243|208.68|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3243||||3243|940|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3243||||3243|208.68|2237.67|208.68
61272146|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3243||||3243|417.37|2237.67|208.68
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|AARP [1000]|AARP [100000]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|AETNA [1015]|AETNA [101529]|3176||||3176|880|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3176||||3176|306.74|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3176||||3176|862.5|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3176||||3176|556.77|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3176||||3176|1150|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3176||||3176|1150|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3176||||3176|306.74|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3176||||3176|650|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3176||||3176|2191.44|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3176||||3176|460.15|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3176||||3176|880|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3176||||3176|306.74|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3176||||3176|880|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3176||||3176|306.74|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3176||||3176|306.74|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3176||||3176|2191.44|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3176||||3176|306.74|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|Self-pay|Self-pay|3176||||3176|1111.6|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3176||||3176|306.74|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3176||||3176|306.74|2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3176||||3176||2191.44|306.74
61272147|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3176||||3176||2191.44|306.74
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|AARP [1000]|AARP [100000]|3150||||3150|940|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3150||||3150|210.77|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|3150||||3150|880|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3150||||3150|212.84|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3150||||3150|208.68|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3150||||3150|208.68|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3150||||3150|862.5|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3150||||3150|283.42|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3150||||3150|1150|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3150||||3150|1150|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3150||||3150|212.84|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3150||||3150|208.68|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3150||||3150|650|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3150||||3150|2173.5|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3150||||3150|287.66|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3150||||3150|223.5|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3150||||3150|880|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3150||||3150|212.84|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3150||||3150|208.68|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3150||||3150|880|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3150||||3150|212.84|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3150||||3150|212.84|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3150||||3150|2173.5|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3150||||3150|212.84|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|Self-pay|Self-pay|3150||||3150|1102.5|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3150||||3150|212.84|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3150||||3150|212.84|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3150||||3150|940|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3150||||3150|208.68|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3150||||3150|208.68|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3150||||3150|940|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3150||||3150|208.68|2173.5|208.68
61272148|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3150||||3150|417.37|2173.5|208.68
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|AARP [1000]|AARP [100000]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|AETNA [1015]|AETNA [101529]|3862||||3862|880|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3862||||3862|305.06|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|3862||||3862|862.5|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3862||||3862|556.77|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3862||||3862|1150|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3862||||3862|1150|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3862||||3862|305.06|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|3862||||3862|650|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3862||||3862|2664.78|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3862||||3862|460.15|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3862||||3862|880|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3862||||3862|305.06|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3862||||3862|880|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3862||||3862|305.06|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3862||||3862|305.06|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3862||||3862|2664.78|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3862||||3862|305.06|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|Self-pay|Self-pay|3862||||3862|1351.7|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3862||||3862|305.06|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3862||||3862|305.06|2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3862||||3862||2664.78|305.06
61272149|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3862||||3862||2664.78|305.06
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|4400||||4400|940|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4400||||4400|337.15|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4400||||4400|880|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4400||||4400|359.86|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4400||||4400|333.81|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4400||||4400|333.81|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|4400||||4400|862.5|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4400||||4400|556.77|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4400||||4400|1150|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4400||||4400|1150|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4400||||4400|359.86|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4400||||4400|333.81|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|4400||||4400|650|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4400||||4400|3036|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4400||||4400|460.15|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4400||||4400|357.52|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4400||||4400|880|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4400||||4400|359.86|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4400||||4400|333.81|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4400||||4400|880|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4400||||4400|359.86|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4400||||4400|359.86|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4400||||4400|3036|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4400||||4400|359.86|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|Self-pay|Self-pay|4400||||4400|1540|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4400||||4400|359.86|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4400||||4400|359.86|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4400||||4400|940|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4400||||4400|333.81|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4400||||4400|333.81|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4400||||4400|940|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4400||||4400|333.81|3036|333.81
61272156|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR C-SPINE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4400||||4400|667.63|3036|333.81
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|5084||||5084|880|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5084||||5084|360.53|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|5084||||5084|862.5|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5084||||5084|556.77|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5084||||5084|1150|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5084||||5084|1150|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5084||||5084|360.53|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|5084||||5084|650|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|5084||||5084|3507.96|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5084||||5084|460.15|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5084||||5084|880|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5084||||5084|360.53|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5084||||5084|880|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5084||||5084|360.53|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|5084||||5084|360.53|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|5084||||5084|3507.96|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5084||||5084|360.53|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|Self-pay|Self-pay|5084||||5084|1779.4|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5084||||5084|360.53|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5084||||5084|360.53|3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5084||||5084||3507.96|360.53
61272157|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR T-SPINE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5084||||5084||3507.96|360.53
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|AARP [1000]|AARP [100000]|4814||||4814|940|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4814||||4814|337.15|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4814||||4814|880|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4814||||4814|359.19|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4814||||4814|333.81|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4814||||4814|333.81|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|4814||||4814|862.5|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4814||||4814|556.77|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4814||||4814|1150|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4814||||4814|1150|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4814||||4814|359.19|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4814||||4814|333.81|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|4814||||4814|650|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4814||||4814|3321.66|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4814||||4814|460.15|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4814||||4814|357.52|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4814||||4814|880|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4814||||4814|359.19|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4814||||4814|333.81|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4814||||4814|880|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4814||||4814|359.19|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4814||||4814|359.19|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4814||||4814|3321.66|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4814||||4814|359.19|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|Self-pay|Self-pay|4814||||4814|1684.9|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4814||||4814|359.19|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4814||||4814|359.19|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4814||||4814|940|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4814||||4814|333.81|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4814||||4814|333.81|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4814||||4814|940|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4814||||4814|333.81|3321.66|333.81
61272158|EAP|0612 - MAGNETIC RESONANCE TECHNOLOGY-MRI-SPINAL CO|HC MR L-SPINE W/ & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4814||||4814|667.63|3321.66|333.81
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AARP [1000]|AARP [100000]|2921||||2921|940|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2921||||2921|210.77|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2921||||2921|880|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2921||||2921|232.31|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2921||||2921|208.68|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2921||||2921|208.68|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2921||||2921|862.5|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2921||||2921|283.42|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2921||||2921|1150|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2921||||2921|1150|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2921||||2921|232.31|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2921||||2921|208.68|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2921||||2921|650|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2921||||2921|2015.49|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2921||||2921|287.66|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2921||||2921|223.5|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2921||||2921|880|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2921||||2921|232.31|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2921||||2921|208.68|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2921||||2921|880|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2921||||2921|232.31|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2921||||2921|232.31|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2921||||2921|2015.49|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2921||||2921|232.31|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|Self-pay|Self-pay|2921||||2921|1022.35|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2921||||2921|232.31|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2921||||2921|232.31|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2921||||2921|940|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2921||||2921|208.68|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2921||||2921|208.68|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2921||||2921|940|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2921||||2921|208.68|2015.49|208.68
61472195|EAP|0610 - MAGNETIC RESONANCE TECHNOLOGY-GENERAL|HC PELVIS W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2921||||2921|417.37|2015.49|208.68
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|AARP [1000]|AARP [100000]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|AETNA [1015]|AETNA [101529]|666||||666|666|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|666||||666|197.47|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|BCBS [1155]|BCBS UTHCT [115568]|666||||666|313.02|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|666||||666|281.28|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|666||||666|333|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|666||||666|419.58|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|666||||666|197.47|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|CIGNA [1260]|CIGNA GWH [126023]|666||||666|650|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|666||||666|459.54|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|666||||666|287.66|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|666||||666|666|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|666||||666|197.47|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|666||||666|666|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|666||||666|197.47|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|666||||666|197.47|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|666||||666|459.54|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|666||||666|197.47|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|Self-pay|Self-pay|666||||666|233.1|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|666||||666|197.47|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|666||||666|197.47|666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|666||||666||666|197.47
61477046|EAP|0614 - MAGNETIC RESONANCE TECHNOLOGY-MRI-OTHER|HC MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|666||||666||666|197.47
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|AARP [1000]|AARP [100000]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2588||||2588|880|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2588||||2588|232.31|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2588||||2588|862.5|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2588||||2588|283.42|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2588||||2588|1150|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2588||||2588|1150|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2588||||2588|232.31|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2588||||2588|650|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2588||||2588|1785.72|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2588||||2588|287.66|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2588||||2588|880|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2588||||2588|232.31|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2588||||2588|880|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2588||||2588|232.31|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2588||||2588|232.31|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2588||||2588|1785.72|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2588||||2588|232.31|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|Self-pay|Self-pay|2588||||2588|905.8|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2588||||2588|232.31|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2588||||2588|232.31|1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2588||||2588||1785.72|232.31
61570544|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA BRAIN W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2588||||2588||1785.72|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AARP [1000]|AARP [100000]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|2721||||2721|880|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2721||||2721|232.31|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2721||||2721|862.5|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2721||||2721|283.42|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2721||||2721|1150|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2721||||2721|1150|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2721||||2721|232.31|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2721||||2721|650|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2721||||2721|1877.49|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2721||||2721|287.66|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2721||||2721|880|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2721||||2721|232.31|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2721||||2721|880|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2721||||2721|232.31|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2721||||2721|232.31|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2721||||2721|1877.49|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2721||||2721|232.31|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|Self-pay|Self-pay|2721||||2721|952.35|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2721||||2721|232.31|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2721||||2721|232.31|1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2721||||2721||1877.49|232.31
61570547|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2721||||2721||1877.49|232.31
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|AARP [1000]|AARP [100000]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|AETNA [1015]|AETNA [101529]|2745||||2745|880|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2745||||2745|252.74|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|2745||||2745|862.5|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2745||||2745|308.34|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2745||||2745|1150|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2745||||2745|1150|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2745||||2745|252.74|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|2745||||2745|650|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2745||||2745|1894.05|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2745||||2745|460.15|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2745||||2745|880|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2745||||2745|252.74|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2745||||2745|880|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2745||||2745|252.74|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2745||||2745|252.74|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2745||||2745|1894.05|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2745||||2745|252.74|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|Self-pay|Self-pay|2745||||2745|960.75|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2745||||2745|252.74|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2745||||2745|252.74|1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2745||||2745||1894.05|252.74
61570548|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W/CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2745||||2745||1894.05|252.74
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|AARP [1000]|AARP [100000]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|AETNA [1015]|AETNA [101529]|4667||||4667|880|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4667||||4667|456.37|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|BCBS [1155]|BCBS UTHCT [115568]|4667||||4667|862.5|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4667||||4667|556.77|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4667||||4667|1150|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4667||||4667|1150|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4667||||4667|456.37|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|CIGNA [1260]|CIGNA GWH [126023]|4667||||4667|650|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4667||||4667|3220.23|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4667||||4667|460.15|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4667||||4667|880|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4667||||4667|456.37|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4667||||4667|880|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4667||||4667|456.37|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4667||||4667|456.37|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4667||||4667|3220.23|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4667||||4667|456.37|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|Self-pay|Self-pay|4667||||4667|1633.45|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4667||||4667|456.37|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4667||||4667|456.37|3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4667||||4667||3220.23|456.37
61570549|EAP|0615 - MAGNETIC RESONANCE TECHNOLOGY-MRA-HEAD AND|HC MRV/MRA NECK W & W/O CONTRAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4667||||4667||3220.23|456.37
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|AARP [1000]|AARP [100000]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|AETNA [1015]|AETNA [101529]|1066||||1066|880|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1066||||1066|316.07|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|BCBS [1155]|BCBS UTHCT [115568]|1066||||1066|501.02|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1066||||1066|308.34|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1066||||1066|533|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1066||||1066|671.58|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1066||||1066|316.07|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|CIGNA [1260]|CIGNA GWH [126023]|1066||||1066|650|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1066||||1066|735.54|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1066||||1066|460.15|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1066||||1066|880|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1066||||1066|316.07|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1066||||1066|880|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1066||||1066|316.07|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1066||||1066|316.07|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1066||||1066|735.54|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1066||||1066|316.07|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|Self-pay|Self-pay|1066||||1066|373.1|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1066||||1066|316.07|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1066||||1066|316.07|880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1066||||1066||880|308.34
61808936|EAP|0618 - MAGNETIC RESONANCE TECHNOLOGY-MRA-OTHER|HC MRA EXTREMITY UPPER W/WO CON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1066||||1066||880|308.34
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901001|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVICORE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901002|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDCURRENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901003|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM MEDICALIS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901004|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM NDSC|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901007|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AIM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901008|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CRANBERRY PK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901009|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SAGE HEALTH|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901010|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM STANSON|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901011|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM QUALIFIED NOS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AARP [1000]|AARP [100000]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01|0.01|0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901012|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM AGILEMD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901013|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EVIDENCECARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901014|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INVENIQA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901015|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM RELIANT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901016|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM SPEED OF CARE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901017|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM HEALTHHELP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901018|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INFINX|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901019|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM LOGICNETS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901020|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM CURBSIDE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901021|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM EHEALTHLINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901022|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM INTERMOUNTAIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AARP [1000]|AARP [100000]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AETNA [1015]|AETNA [101529]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS [1155]|BCBS UTHCT [115568]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|CIGNA [1260]|CIGNA GWH [126023]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|0.01||||0.01|0.01|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|Self-pay|Self-pay|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.01||||0.01|0|0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.01||||0.01||0.01|0.01
61901023|EAP|0619 - MAGNETIC RESONANCE TECHNOLOGY-OTHER MRT|HC CDSM PERSIVIA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.01||||0.01||0.01|0.01
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.64||||2.64|1.16|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.64||||2.64|0.78|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.64||||2.64|1.24|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.64||||2.64|1.32|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.64||||2.64|1.32|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.64||||2.64|1.66|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.64||||2.64|0.78|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.64||||2.64|1.45|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.64||||2.64|1.82|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.64||||2.64|1.32|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.64||||2.64|1.16|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.64||||2.64|0.78|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.64||||2.64|1.16|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.64||||2.64|0.78|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.64||||2.64|0.78|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.64||||2.64|1.82|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.64||||2.64|0.78|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|Self-pay|Self-pay|2.64||||2.64|0.92|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.64||||2.64|0.78|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.64||||2.64|0.78|1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.64||||2.64||1.82|0.78
6193|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENAZOPYRIDINE 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.64||||2.64||1.82|0.78
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|AARP [1000]|AARP [100000]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|AETNA [1015]|AETNA [101529]|214.08||||214.08|94.41|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214.08||||214.08|63.47|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|BCBS [1155]|BCBS UTHCT [115568]|214.08||||214.08|100.62|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214.08||||214.08|107.04|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214.08||||214.08|107.04|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214.08||||214.08|134.87|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214.08||||214.08|63.47|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|CIGNA [1260]|CIGNA GWH [126023]|214.08||||214.08|117.74|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|214.08||||214.08|147.72|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214.08||||214.08|107.04|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214.08||||214.08|94.41|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214.08||||214.08|63.47|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214.08||||214.08|94.41|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214.08||||214.08|63.47|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|214.08||||214.08|63.47|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|214.08||||214.08|147.72|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214.08||||214.08|63.47|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|Self-pay|Self-pay|214.08||||214.08|74.93|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214.08||||214.08|63.47|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214.08||||214.08|63.47|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214.08||||214.08||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|AARP [1000]|AARP [100000]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|AETNA [1015]|AETNA [101529]|0.47||||0.47|0.21|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.47||||0.47|0.14|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.47||||0.47|0.22|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.47||||0.47|0.24|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.47||||0.47|0.24|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.47||||0.47|0.3|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.47||||0.47|0.14|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.47||||0.47|0.26|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.47||||0.47|0.32|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.47||||0.47|0.24|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.47||||0.47|0.21|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.47||||0.47|0.14|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.47||||0.47|0.21|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.47||||0.47|0.14|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.47||||0.47|0.14|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.47||||0.47|0.32|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.47||||0.47|0.14|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|Self-pay|Self-pay|0.47||||0.47|0.16|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.47||||0.47|0.14|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.47||||0.47|0.14|147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.47||||0.47||147.72|0.14
6212|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 20 MG/5 ML (4 MG/ML) ORAL ELIXIR REPACK|7.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.47||||0.47||147.72|0.14
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.18||||1.18|0.52|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.18||||1.18|0.35|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.18||||1.18|0.55|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.18||||1.18|0.59|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.18||||1.18|0.59|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.18||||1.18|0.74|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.18||||1.18|0.35|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.18||||1.18|0.65|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.18||||1.18|0.81|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.18||||1.18|0.59|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.18||||1.18|0.52|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.18||||1.18|0.35|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.18||||1.18|0.52|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.18||||1.18|0.35|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.18||||1.18|0.35|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.18||||1.18|0.81|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.18||||1.18|0.35|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|Self-pay|Self-pay|1.18||||1.18|0.41|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.18||||1.18|0.35|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.18||||1.18|0.35|0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.18||||1.18||0.81|0.35
6217|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENOBARBITAL 32.4 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.18||||1.18||0.81|0.35
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|12.4||||12.4|8.45|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.4||||12.4|3.68|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|12.4||||12.4|5.83|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.4||||12.4|0|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.4||||12.4|6.2|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.4||||12.4|7.81|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.4||||12.4|3.68|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|12.4||||12.4|6.82|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12.4||||12.4|8.56|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.4||||12.4|6.2|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.4||||12.4|8.45|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.4||||12.4|3.68|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.4||||12.4|8.45|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.4||||12.4|3.68|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.4||||12.4|3.68|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12.4||||12.4|8.56|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.4||||12.4|3.68|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|12.4||||12.4|4.34|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.4||||12.4|3.68|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.4||||12.4|3.68|8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.4||||12.4||8.56|3.68
6242|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PHENYLEPHRINE 10 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.4||||12.4||8.56|3.68
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.66||||1.66|0.73|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.66||||1.66|0.49|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.66||||1.66|0.78|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.66||||1.66|0.83|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.66||||1.66|0.83|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.66||||1.66|1.05|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.66||||1.66|0.49|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.66||||1.66|0.91|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.66||||1.66|1.15|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.66||||1.66|0.83|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.66||||1.66|0.73|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.66||||1.66|0.49|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.66||||1.66|0.73|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.66||||1.66|0.49|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.66||||1.66|0.49|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.66||||1.66|1.15|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.66||||1.66|0.49|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.66||||1.66|0.58|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.66||||1.66|0.49|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.66||||1.66|0.49|1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.66||||1.66||1.15|0.49
6257|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PHENYTOIN SODIUM EXTENDED 100 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.66||||1.66||1.15|0.49
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|244.46||||244.46|107.81|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|244.46||||244.46|72.48|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|244.46||||244.46|114.9|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|244.46||||244.46|122.23|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|244.46||||244.46|122.23|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|244.46||||244.46|154.01|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|244.46||||244.46|72.48|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|244.46||||244.46|134.45|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|244.46||||244.46|168.68|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|244.46||||244.46|122.23|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|244.46||||244.46|107.81|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|244.46||||244.46|72.48|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|244.46||||244.46|107.81|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|244.46||||244.46|72.48|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|244.46||||244.46|72.48|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|244.46||||244.46|168.68|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|244.46||||244.46|72.48|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|Self-pay|Self-pay|244.46||||244.46|85.56|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|244.46||||244.46|72.48|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|244.46||||244.46|72.48|168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|244.46||||244.46||168.68|72.48
6279|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 1 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|244.46||||244.46||168.68|72.48
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|250.04||||250.04|110.27|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|250.04||||250.04|74.14|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|250.04||||250.04|117.52|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|250.04||||250.04|125.02|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|250.04||||250.04|125.02|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|250.04||||250.04|157.53|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|250.04||||250.04|74.14|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|250.04||||250.04|137.52|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|250.04||||250.04|172.53|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|250.04||||250.04|125.02|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|250.04||||250.04|110.27|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|250.04||||250.04|74.14|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|250.04||||250.04|110.27|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|250.04||||250.04|74.14|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|250.04||||250.04|74.14|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|250.04||||250.04|172.53|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|250.04||||250.04|74.14|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|Self-pay|Self-pay|250.04||||250.04|87.51|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|250.04||||250.04|74.14|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|250.04||||250.04|74.14|172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|250.04||||250.04||172.53|74.14
6280|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PILOCARPINE 2 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|250.04||||250.04||172.53|74.14
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|10.61||||10.61|4.68|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.61||||10.61|3.15|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|10.61||||10.61|4.99|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.61||||10.61|5.31|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.61||||10.61|5.31|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.61||||10.61|6.68|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.61||||10.61|3.15|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|10.61||||10.61|5.84|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.61||||10.61|7.32|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.61||||10.61|5.31|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.61||||10.61|4.68|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.61||||10.61|3.15|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.61||||10.61|4.68|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.61||||10.61|3.15|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.61||||10.61|3.15|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.61||||10.61|7.32|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.61||||10.61|3.15|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|10.61||||10.61|3.71|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.61||||10.61|3.15|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.61||||10.61|3.15|7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.61||||10.61||7.32|3.15
6420|ERX|0250 - PHARMACY-GENERAL|POTASSIUM ACETATE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.61||||10.61||7.32|3.15
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|5.43||||5.43|4.6|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|5.43||||5.43|4.32|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.43||||5.43|1.61|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|5.43||||5.43|2.55|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.43||||5.43|0|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.43||||5.43|2.72|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.43||||5.43|3.42|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.43||||5.43|1.61|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|5.43||||5.43|2.99|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5.43||||5.43|3.75|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.43||||5.43|0.2|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.43||||5.43|4.32|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.43||||5.43|1.61|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.43||||5.43|4.32|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.43||||5.43|1.61|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.43||||5.43|1.61|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5.43||||5.43|3.75|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.43||||5.43|1.61|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|5.43||||5.43|1.9|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.43||||5.43|1.61|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.43||||5.43|1.61|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.43||||5.43|4.6|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.43||||5.43|4.6|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.43||||5.43||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|14.08||||14.08|9.2|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.08||||14.08||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|14.08||||14.08|8.64|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.08||||14.08|4.17|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.08||||14.08||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.08||||14.08||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|14.08||||14.08|6.62|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.08||||14.08|0|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.08||||14.08|7.04|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.08||||14.08|8.87|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.08||||14.08|4.17|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.08||||14.08||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|14.08||||14.08|7.74|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.08||||14.08|9.72|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.08||||14.08|0.2|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.08||||14.08||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.08||||14.08|8.64|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.08||||14.08|4.17|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.08||||14.08||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.08||||14.08|8.64|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.08||||14.08|4.17|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.08||||14.08|4.17|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.08||||14.08|9.72|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.08||||14.08|4.17|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|14.08||||14.08|4.93|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.08||||14.08|4.17|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.08||||14.08|4.17|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.08||||14.08|9.2|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.08||||14.08||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.08||||14.08||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.08||||14.08|9.2|9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.08||||14.08||9.72|0.2
6429|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|POTASSIUM CHLORIDE 2 MEQ/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.08||||14.08||9.72|0.2
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AARP [1000]|AARP [100000]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AETNA [1015]|AETNA [101529]|8.72||||8.72|3.85|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.72||||8.72|2.59|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|BCBS [1155]|BCBS UTHCT [115568]|8.72||||8.72|4.1|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.72||||8.72|4.36|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.72||||8.72|4.36|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.72||||8.72|5.49|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.72||||8.72|2.59|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|CIGNA [1260]|CIGNA GWH [126023]|8.72||||8.72|4.8|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.72||||8.72|6.02|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.72||||8.72|4.36|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.72||||8.72|3.85|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.72||||8.72|2.59|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.72||||8.72|3.85|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.72||||8.72|2.59|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.72||||8.72|2.59|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.72||||8.72|6.02|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.72||||8.72|2.59|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|Self-pay|Self-pay|8.72||||8.72|3.05|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.72||||8.72|2.59|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.72||||8.72|2.59|6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.72||||8.72||6.02|2.59
6434|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ ORAL PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.72||||8.72||6.02|2.59
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|AARP [1000]|AARP [100000]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|AETNA [1015]|AETNA [101529]|2.03||||2.03|0.9|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.03||||2.03|0.6|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|BCBS [1155]|BCBS UTHCT [115568]|2.03||||2.03|0.95|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.03||||2.03|1.02|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.03||||2.03|1.02|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.03||||2.03|1.28|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.03||||2.03|0.6|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|CIGNA [1260]|CIGNA GWH [126023]|2.03||||2.03|1.12|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.03||||2.03|1.4|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.03||||2.03|1.02|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.03||||2.03|0.9|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.03||||2.03|0.6|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.03||||2.03|0.9|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.03||||2.03|0.6|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.03||||2.03|0.6|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.03||||2.03|1.4|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.03||||2.03|0.6|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|Self-pay|Self-pay|2.03||||2.03|0.71|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.03||||2.03|0.6|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.03||||2.03|0.6|1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.03||||2.03||1.4|0.6
6445|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM IODIDE 1 GRAM/ML ORAL SOLUTION|0.05 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.03||||2.03||1.4|0.6
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|4.62||||4.62|2.04|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.62||||4.62|1.37|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|4.62||||4.62|2.17|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.62||||4.62|2.31|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.62||||4.62|2.31|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.62||||4.62|2.91|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.62||||4.62|1.37|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|4.62||||4.62|2.54|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|4.62||||4.62|3.19|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.62||||4.62|2.31|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.62||||4.62|2.04|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.62||||4.62|1.37|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.62||||4.62|2.04|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.62||||4.62|1.37|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.62||||4.62|1.37|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|4.62||||4.62|3.19|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.62||||4.62|1.37|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|Self-pay|Self-pay|4.62||||4.62|1.62|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.62||||4.62|1.37|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.62||||4.62|1.37|3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.62||||4.62||3.19|1.37
6468|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 1 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.62||||4.62||3.19|1.37
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|6.44||||6.44|2.84|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.44||||6.44|1.91|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|6.44||||6.44|3.03|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.44||||6.44|3.22|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.44||||6.44|3.22|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.44||||6.44|4.06|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.44||||6.44|1.91|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|6.44||||6.44|3.54|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|6.44||||6.44|4.44|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.44||||6.44|3.22|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.44||||6.44|2.84|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.44||||6.44|1.91|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.44||||6.44|2.84|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.44||||6.44|1.91|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.44||||6.44|1.91|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|6.44||||6.44|4.44|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.44||||6.44|1.91|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|Self-pay|Self-pay|6.44||||6.44|2.25|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.44||||6.44|1.91|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.44||||6.44|1.91|4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.44||||6.44||4.44|1.91
6469|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 2 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.44||||6.44||4.44|1.91
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|2.29||||2.29|1.01|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.29||||2.29|0.68|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|2.29||||2.29|1.08|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.29||||2.29|1.15|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.29||||2.29|1.15|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.29||||2.29|1.44|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.29||||2.29|0.68|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|2.29||||2.29|1.26|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|2.29||||2.29|1.58|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.29||||2.29|1.15|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.29||||2.29|1.01|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.29||||2.29|0.68|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.29||||2.29|1.01|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.29||||2.29|0.68|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.29||||2.29|0.68|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|2.29||||2.29|1.58|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.29||||2.29|0.68|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|Self-pay|Self-pay|2.29||||2.29|0.8|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.29||||2.29|0.68|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.29||||2.29|0.68|1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.29||||2.29||1.58|0.68
6470|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRAZOSIN 5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.29||||2.29||1.58|0.68
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AARP [1000]|AARP [100000]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|136.4||||136.4|60.15|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|136.4||||136.4|40.44|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|136.4||||136.4|64.11|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|136.4||||136.4|68.2|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|136.4||||136.4|68.2|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|136.4||||136.4|85.93|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|136.4||||136.4|40.44|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|136.4||||136.4|75.02|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|136.4||||136.4|94.12|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|136.4||||136.4|68.2|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|136.4||||136.4|60.15|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|136.4||||136.4|40.44|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|136.4||||136.4|60.15|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|136.4||||136.4|40.44|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|136.4||||136.4|40.44|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|136.4||||136.4|94.12|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|136.4||||136.4|40.44|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|Self-pay|Self-pay|136.4||||136.4|47.74|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|136.4||||136.4|40.44|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|136.4||||136.4|40.44|94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|136.4||||136.4||94.12|40.44
6487|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PREDNISOLONE ACETATE 1 % EYE DROPS,SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|136.4||||136.4||94.12|40.44
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.63||||0.63|0.02|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.63||||0.63|0.19|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.63||||0.63|0.3|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.63||||0.63|0|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.63||||0.63|0.32|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.63||||0.63|0.4|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.63||||0.63|0.19|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.63||||0.63|0.35|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.63||||0.63|0.43|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.63||||0.63|0.01|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.63||||0.63|0.02|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.63||||0.63|0.19|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.63||||0.63|0.02|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.63||||0.63|0.19|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.63||||0.63|0.19|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.63||||0.63|0.43|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.63||||0.63|0.19|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.63||||0.63|0.22|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.63||||0.63|0.19|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.63||||0.63|0.19|0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.63||||0.63||0.43|0.01
6493|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.63||||0.63||0.43|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.67||||0.67|0.24|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.67||||0.67|0.2|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.67||||0.67|0.31|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.67||||0.67|0|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.67||||0.67|0.34|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.67||||0.67|0.42|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.67||||0.67|0.2|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.67||||0.67|0.37|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.67||||0.67|0.46|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.67||||0.67|0.01|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.67||||0.67|0.24|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.67||||0.67|0.2|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.67||||0.67|0.24|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.67||||0.67|0.2|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.67||||0.67|0.2|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.67||||0.67|0.46|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.67||||0.67|0.2|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.67||||0.67|0.23|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.67||||0.67|0.2|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.67||||0.67|0.2|0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.67||||0.67||0.46|0.01
6494|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.67||||0.67||0.46|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.41||||0.41|0.07|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.41||||0.41|0.12|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.41||||0.41|0.19|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.41||||0.41|0|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.41||||0.41|0.21|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.41||||0.41|0.26|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.41||||0.41|0.12|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.41||||0.41|0.23|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.41||||0.41|0.28|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.41||||0.41|0.01|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.41||||0.41|0.07|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.41||||0.41|0.12|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.41||||0.41|0.07|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.41||||0.41|0.12|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.41||||0.41|0.12|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.41||||0.41|0.28|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.41||||0.41|0.12|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.41||||0.41|0.14|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.41||||0.41|0.12|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.41||||0.41|0.12|0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.41||||0.41||0.28|0.01
6495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.41||||0.41||0.28|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.65||||0.65|0.48|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.65||||0.65|0.19|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.65||||0.65|0.31|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.65||||0.65|0|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.65||||0.65|0.33|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.65||||0.65|0.41|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.65||||0.65|0.19|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.65||||0.65|0.36|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.65||||0.65|0.45|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.65||||0.65|0.01|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.65||||0.65|0.48|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.65||||0.65|0.19|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.65||||0.65|0.48|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.65||||0.65|0.19|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.65||||0.65|0.19|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.65||||0.65|0.45|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.65||||0.65|0.19|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|Self-pay|Self-pay|0.65||||0.65|0.23|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.65||||0.65|0.19|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.65||||0.65|0.19|0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.65||||0.65||0.48|0.01
6496|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.65||||0.65||0.48|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.53||||0.53|0.12|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.53||||0.53|0.16|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.53||||0.53|0.25|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.53||||0.53|0|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.53||||0.53|0.27|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.53||||0.53|0.33|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.53||||0.53|0.16|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.53||||0.53|0.29|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.53||||0.53|0.37|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.53||||0.53|0.01|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.53||||0.53|0.12|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.53||||0.53|0.16|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.53||||0.53|0.12|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.53||||0.53|0.16|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.53||||0.53|0.16|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.53||||0.53|0.37|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.53||||0.53|0.16|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.53||||0.53|0.19|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.53||||0.53|0.16|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.53||||0.53|0.16|0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.53||||0.53||0.37|0.01
6497|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.53||||0.53||0.37|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.04||||1.04|1.04|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.04||||1.04|0.31|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.04||||1.04|0.49|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.04||||1.04|0|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.04||||1.04|0.52|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.04||||1.04|0.66|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.04||||1.04|0.31|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.04||||1.04|0.57|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.04||||1.04|0.72|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.04||||1.04|0.01|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.04||||1.04|1.04|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.04||||1.04|0.31|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.04||||1.04|1.04|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.04||||1.04|0.31|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.04||||1.04|0.31|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.04||||1.04|0.72|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.04||||1.04|0.31|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.04||||1.04|0.36|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.04||||1.04|0.31|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.04||||1.04|0.31|1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.04||||1.04||1.04|0.01
6498|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PREDNISONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.04||||1.04||1.04|0.01
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|AARP [1000]|AARP [100000]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|280.55||||280.55|123.72|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|280.55||||280.55|83.18|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|280.55||||280.55|131.86|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|280.55||||280.55|140.28|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|280.55||||280.55|140.28|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|280.55||||280.55|176.75|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|280.55||||280.55|83.18|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|280.55||||280.55|154.3|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|280.55||||280.55|193.58|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|280.55||||280.55|140.28|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|280.55||||280.55|123.72|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|280.55||||280.55|83.18|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|280.55||||280.55|123.72|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|280.55||||280.55|83.18|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|280.55||||280.55|83.18|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|280.55||||280.55|193.58|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|280.55||||280.55|83.18|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|Self-pay|Self-pay|280.55||||280.55|98.19|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|280.55||||280.55|83.18|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|280.55||||280.55|83.18|193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|280.55||||280.55||193.58|83.18
654|ERX|0250 - PHARMACY-GENERAL|ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|280.55||||280.55||193.58|83.18
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.1||||2.1|0.93|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.1||||2.1|0.62|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.1||||2.1|0.99|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.1||||2.1|1.05|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.1||||2.1|1.05|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.1||||2.1|1.32|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.1||||2.1|0.62|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.1||||2.1|1.16|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.1||||2.1|1.45|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.1||||2.1|1.05|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.1||||2.1|0.93|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.1||||2.1|0.62|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.1||||2.1|0.93|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.1||||2.1|0.62|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.1||||2.1|0.62|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.1||||2.1|1.45|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.1||||2.1|0.62|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|Self-pay|Self-pay|2.1||||2.1|0.73|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.1||||2.1|0.62|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.1||||2.1|0.62|1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.1||||2.1||1.45|0.62
6544|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRIMIDONE 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.1||||2.1||1.45|0.62
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|55.8||||55.8|15.43|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55.8||||55.8|16.54|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|55.8||||55.8|26.23|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|55.8||||55.8|0|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|55.8||||55.8|27.9|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|55.8||||55.8|35.15|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|55.8||||55.8|16.54|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|55.8||||55.8|30.69|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|55.8||||55.8|38.5|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|55.8||||55.8|6.34|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55.8||||55.8|15.43|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|55.8||||55.8|16.54|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55.8||||55.8|15.43|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|55.8||||55.8|16.54|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|55.8||||55.8|16.54|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|55.8||||55.8|38.5|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|55.8||||55.8|16.54|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|Self-pay|Self-pay|55.8||||55.8|19.53|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|55.8||||55.8|16.54|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|55.8||||55.8|16.54|38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|55.8||||55.8||38.5|6.34
6580|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|55.8||||55.8||38.5|6.34
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1||||1|0.55|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1||||1|0.3|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1||||1|0.47|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1||||1|0|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1||||1|0.5|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1||||1|0.63|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1||||1|0.3|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1||||1|0.55|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1||||1|0.69|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1||||1|0.38|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1||||1|0.55|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1||||1|0.3|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1||||1|0.55|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1||||1|0.3|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1||||1|0.3|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1||||1|0.69|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1||||1|0.3|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|Self-pay|Self-pay|1||||1|0.35|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1||||1|0.3|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1||||1|0.3|0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1||||1||0.69|0.3
6583|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROCHLORPERAZINE MALEATE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1||||1||0.69|0.3
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.4||||1.4|0.24|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.4||||1.4|0.42|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.4||||1.4|0.66|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.4||||1.4|0|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.4||||1.4|0.7|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.4||||1.4|0.88|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.4||||1.4|0.42|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.4||||1.4|0.77|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.4||||1.4|0.97|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.4||||1.4|0.7|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.4||||1.4|0.24|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.4||||1.4|0.42|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.4||||1.4|0.24|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.4||||1.4|0.42|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.4||||1.4|0.42|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.4||||1.4|0.97|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.4||||1.4|0.42|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.4||||1.4|0.49|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.4||||1.4|0.42|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.4||||1.4|0.42|0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.4||||1.4||0.97|0.24
6621|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.4||||1.4||0.97|0.24
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.29||||1.29|0.48|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.29||||1.29|0.38|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.29||||1.29|0.61|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.29||||1.29|0|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.29||||1.29|0.65|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.29||||1.29|0.81|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.29||||1.29|0.38|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.29||||1.29|0.71|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.29||||1.29|0.89|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.29||||1.29|0.65|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.29||||1.29|0.48|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.29||||1.29|0.38|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.29||||1.29|0.48|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.29||||1.29|0.38|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.29||||1.29|0.38|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.29||||1.29|0.89|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.29||||1.29|0.38|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|1.29||||1.29|0.45|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.29||||1.29|0.38|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.29||||1.29|0.38|0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.29||||1.29||0.89|0.38
6622|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROMETHAZINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.29||||1.29||0.89|0.38
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.07||||0.07|0.03|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.07||||0.07|0.02|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.07||||0.07|0.03|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.07||||0.07|0.04|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.07||||0.07|0.04|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.07||||0.07|0.04|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.07||||0.07|0.02|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.07||||0.07|0.04|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.07||||0.07|0.05|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.07||||0.07|0.04|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.07||||0.07|0.03|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.07||||0.07|0.02|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.07||||0.07|0.03|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.07||||0.07|0.02|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.07||||0.07|0.02|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.07||||0.07|0.05|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.07||||0.07|0.02|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|Self-pay|Self-pay|0.07||||0.07|0.02|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.07||||0.07|0.02|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.07||||0.07|0.02|0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.07||||0.07||0.05|0.02
664|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASCORBIC ACID (VITAMIN C) 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.07||||0.07||0.05|0.02
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|108.77||||108.77|47.97|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.77||||108.77|32.25|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|108.77||||108.77|51.12|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.77||||108.77|54.39|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.77||||108.77|54.39|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.77||||108.77|68.53|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.77||||108.77|32.25|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|108.77||||108.77|59.82|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|108.77||||108.77|75.05|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|108.77||||108.77|54.39|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.77||||108.77|47.97|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.77||||108.77|32.25|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.77||||108.77|47.97|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.77||||108.77|32.25|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|108.77||||108.77|32.25|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|108.77||||108.77|75.05|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.77||||108.77|32.25|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|Self-pay|Self-pay|108.77||||108.77|38.07|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|108.77||||108.77|32.25|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.77||||108.77|32.25|75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.77||||108.77||75.05|32.25
6644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPARACAINE 0.5 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.77||||108.77||75.05|32.25
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.73||||0.73|0.32|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.73||||0.73|0.22|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.73||||0.73|0.34|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.73||||0.73|0.37|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.73||||0.73|0.37|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.73||||0.73|0.46|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.73||||0.73|0.22|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.73||||0.73|0.4|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.73||||0.73|0.5|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.73||||0.73|0.37|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.73||||0.73|0.32|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.73||||0.73|0.22|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.73||||0.73|0.32|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.73||||0.73|0.22|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.73||||0.73|0.22|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.73||||0.73|0.5|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.73||||0.73|0.22|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.73||||0.73|0.26|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.73||||0.73|0.22|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.73||||0.73|0.22|0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.73||||0.73||0.5|0.22
6656|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.73||||0.73||0.5|0.22
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.07||||1.07|0.47|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.07||||1.07|0.32|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.07||||1.07|0.5|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.07||||1.07|0.54|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.07||||1.07|0.54|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.07||||1.07|0.67|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.07||||1.07|0.32|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.07||||1.07|0.59|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.07||||1.07|0.74|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.07||||1.07|0.54|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.07||||1.07|0.47|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.07||||1.07|0.32|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.07||||1.07|0.47|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.07||||1.07|0.32|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.07||||1.07|0.32|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.07||||1.07|0.74|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.07||||1.07|0.32|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|Self-pay|Self-pay|1.07||||1.07|0.37|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.07||||1.07|0.32|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.07||||1.07|0.32|0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.07||||1.07||0.74|0.32
6657|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPRANOLOL 20 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.07||||1.07||0.74|0.32
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.33||||2.33|1.03|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.33||||2.33|0.69|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.33||||2.33|1.1|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.33||||2.33|1.17|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.33||||2.33|1.17|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.33||||2.33|1.47|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.33||||2.33|0.69|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.33||||2.33|1.28|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.33||||2.33|1.61|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.33||||2.33|1.17|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.33||||2.33|1.03|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.33||||2.33|0.69|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.33||||2.33|1.03|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.33||||2.33|0.69|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.33||||2.33|0.69|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.33||||2.33|1.61|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.33||||2.33|0.69|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|Self-pay|Self-pay|2.33||||2.33|0.82|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.33||||2.33|0.69|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.33||||2.33|0.69|1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.33||||2.33||1.61|0.69
6662|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PROPYLTHIOURACIL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.33||||2.33||1.61|0.69
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AARP [1000]|AARP [100000]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA [1015]|AETNA [101529]|114.24||||114.24|52.8|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|114.24||||114.24|33.87|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BCBS UTHCT [115568]|114.24||||114.24|53.69|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|114.24||||114.24|0|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|114.24||||114.24|57.12|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|114.24||||114.24|71.97|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|114.24||||114.24|33.87|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA [1260]|CIGNA GWH [126023]|114.24||||114.24|62.83|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|114.24||||114.24|78.83|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|114.24||||114.24|1.4|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|114.24||||114.24|52.8|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|114.24||||114.24|33.87|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|114.24||||114.24|52.8|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|114.24||||114.24|33.87|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|114.24||||114.24|33.87|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|114.24||||114.24|78.83|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|114.24||||114.24|33.87|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|Self-pay|Self-pay|114.24||||114.24|39.98|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|114.24||||114.24|33.87|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|114.24||||114.24|33.87|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|114.24||||114.24||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|38.1||||38.1|10.56|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|38.1||||38.1|11.3|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|38.1||||38.1|17.91|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|38.1||||38.1|0|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|38.1||||38.1|19.05|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|38.1||||38.1|24|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|38.1||||38.1|11.3|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|38.1||||38.1|20.96|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|38.1||||38.1|26.29|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|38.1||||38.1|1.4|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|38.1||||38.1|10.56|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|38.1||||38.1|11.3|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|38.1||||38.1|10.56|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|38.1||||38.1|11.3|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|38.1||||38.1|11.3|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|38.1||||38.1|26.29|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|38.1||||38.1|11.3|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|38.1||||38.1|13.33|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|38.1||||38.1|11.3|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|38.1||||38.1|11.3|78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|38.1||||38.1||78.83|1.4
6677|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|38.1||||38.1||78.83|1.4
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.18||||0.18|0.08|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.18||||0.18|0.05|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.18||||0.18|0.08|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.18||||0.18|0.09|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.18||||0.18|0.09|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.18||||0.18|0.11|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.18||||0.18|0.05|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.18||||0.18|0.1|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.18||||0.18|0.12|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.18||||0.18|0.09|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.18||||0.18|0.08|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.18||||0.18|0.05|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.18||||0.18|0.08|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.18||||0.18|0.05|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.18||||0.18|0.05|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.18||||0.18|0.12|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.18||||0.18|0.05|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|Self-pay|Self-pay|0.18||||0.18|0.06|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.18||||0.18|0.05|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.18||||0.18|0.05|0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.18||||0.18||0.12|0.05
6714|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PSEUDOEPHEDRINE 30 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.18||||0.18||0.12|0.05
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.88||||0.88|0.39|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.88||||0.88|0.26|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.88||||0.88|0.41|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.88||||0.88|0.44|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.88||||0.88|0.44|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.88||||0.88|0.55|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.88||||0.88|0.26|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.88||||0.88|0.48|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.88||||0.88|0.61|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.88||||0.88|0.44|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.88||||0.88|0.39|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.88||||0.88|0.26|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.88||||0.88|0.39|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.88||||0.88|0.26|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.88||||0.88|0.26|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.88||||0.88|0.61|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.88||||0.88|0.26|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.88||||0.88|0.31|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.88||||0.88|0.26|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.88||||0.88|0.26|0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.88||||0.88||0.61|0.26
6746|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.88||||0.88||0.61|0.26
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.73||||0.73|0.32|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.73||||0.73|0.22|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.73||||0.73|0.34|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.73||||0.73|0.37|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.73||||0.73|0.37|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.73||||0.73|0.46|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.73||||0.73|0.22|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.73||||0.73|0.4|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.73||||0.73|0.5|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.73||||0.73|0.37|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.73||||0.73|0.32|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.73||||0.73|0.22|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.73||||0.73|0.32|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.73||||0.73|0.22|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.73||||0.73|0.22|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.73||||0.73|0.5|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.73||||0.73|0.22|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.73||||0.73|0.26|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.73||||0.73|0.22|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.73||||0.73|0.22|0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.73||||0.73||0.5|0.22
6748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PYRIDOXINE (VITAMIN B6) 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.73||||0.73||0.5|0.22
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|3.62||||3.62|1.6|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.62||||3.62|1.07|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|3.62||||3.62|1.7|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.62||||3.62|1.81|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.62||||3.62|1.81|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.62||||3.62|2.28|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.62||||3.62|1.07|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|3.62||||3.62|1.99|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|3.62||||3.62|2.5|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.62||||3.62|1.81|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.62||||3.62|1.6|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.62||||3.62|1.07|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.62||||3.62|1.6|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.62||||3.62|1.07|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.62||||3.62|1.07|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|3.62||||3.62|2.5|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.62||||3.62|1.07|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|3.62||||3.62|1.27|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.62||||3.62|1.07|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.62||||3.62|1.07|2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.62||||3.62||2.5|1.07
693|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASPIRIN 300 MG RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.62||||3.62||2.5|1.07
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|7.96||||7.96|3.51|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.96||||7.96|2.36|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|7.96||||7.96|3.74|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.96||||7.96|3.98|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.96||||7.96|3.98|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.96||||7.96|5.01|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.96||||7.96|2.36|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|7.96||||7.96|4.38|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.96||||7.96|5.49|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.96||||7.96|3.98|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.96||||7.96|3.51|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.96||||7.96|2.36|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.96||||7.96|3.51|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.96||||7.96|2.36|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.96||||7.96|2.36|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.96||||7.96|5.49|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.96||||7.96|2.36|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|Self-pay|Self-pay|7.96||||7.96|2.79|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.96||||7.96|2.36|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.96||||7.96|2.36|5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.96||||7.96||5.49|2.36
70255|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POLYVINYL ALCOHOL-POVIDONE 0.5 %-0.6 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.96||||7.96||5.49|2.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|AARP [1000]|AARP [100000]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|AETNA [1015]|AETNA [101529]|28.19||||28.19|12.43|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.19||||28.19|8.36|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|28.19||||28.19|13.25|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.19||||28.19|14.1|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.19||||28.19|14.1|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.19||||28.19|17.76|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.19||||28.19|8.36|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|28.19||||28.19|15.5|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|28.19||||28.19|19.45|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|28.19||||28.19|14.1|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.19||||28.19|12.43|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.19||||28.19|8.36|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.19||||28.19|12.43|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.19||||28.19|8.36|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|28.19||||28.19|8.36|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|28.19||||28.19|19.45|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.19||||28.19|8.36|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|Self-pay|Self-pay|28.19||||28.19|9.87|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|28.19||||28.19|8.36|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.19||||28.19|8.36|19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.19||||28.19||19.45|8.36
70258|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RISPERIDONE 4 MG DISINTEGRATING TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.19||||28.19||19.45|8.36
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|546.72||||546.72|241.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|546.72||||546.72|162.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|546.72||||546.72|256.96|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|546.72||||546.72|273.36|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|546.72||||546.72|273.36|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|546.72||||546.72|344.43|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|546.72||||546.72|162.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|546.72||||546.72|300.7|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|546.72||||546.72|377.24|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|546.72||||546.72|273.36|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|546.72||||546.72|241.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|546.72||||546.72|162.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|546.72||||546.72|241.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|546.72||||546.72|162.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|546.72||||546.72|162.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|546.72||||546.72|377.24|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|546.72||||546.72|162.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|Self-pay|Self-pay|546.72||||546.72|191.35|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|546.72||||546.72|162.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|546.72||||546.72|162.1|377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|546.72||||546.72||377.24|162.1
70262|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BRIMONIDINE 0.1 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|546.72||||546.72||377.24|162.1
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|3.45||||3.45|1.52|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.45||||3.45|1.02|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|3.45||||3.45|1.62|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.45||||3.45|1.73|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.45||||3.45|1.73|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.45||||3.45|2.17|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.45||||3.45|1.02|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|3.45||||3.45|1.9|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.45||||3.45|2.38|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.45||||3.45|1.73|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.45||||3.45|1.52|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.45||||3.45|1.02|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.45||||3.45|1.52|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.45||||3.45|1.02|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.45||||3.45|1.02|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.45||||3.45|2.38|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.45||||3.45|1.02|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|Self-pay|Self-pay|3.45||||3.45|1.21|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.45||||3.45|1.02|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.45||||3.45|1.02|2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.45||||3.45||2.38|1.02
7028|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 %, BACTERIOSTATIC INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.45||||3.45||2.38|1.02
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AARP [1000]|AARP [100000]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AETNA [1015]|AETNA [101529]|1.69||||1.69|0.75|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.69||||1.69|0.5|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS [1155]|BCBS UTHCT [115568]|1.69||||1.69|0.79|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.69||||1.69|0.85|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.69||||1.69|0.85|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.69||||1.69|1.06|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.69||||1.69|0.5|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|CIGNA [1260]|CIGNA GWH [126023]|1.69||||1.69|0.93|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.69||||1.69|1.17|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.69||||1.69|0.85|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.69||||1.69|0.75|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.69||||1.69|0.5|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.69||||1.69|0.75|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.69||||1.69|0.5|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.69||||1.69|0.5|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.69||||1.69|1.17|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.69||||1.69|0.5|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|Self-pay|Self-pay|1.69||||1.69|0.59|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.69||||1.69|0.5|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.69||||1.69|0.5|1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.69||||1.69||1.17|0.5
70284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM, SODIUM PHOSPHATES 280 MG-160 MG-250 MG ORAL POWDER PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.69||||1.69||1.17|0.5
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.17||||2.17|0.96|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.17||||2.17|0.64|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.17||||2.17|1.02|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.17||||2.17|1.09|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.17||||2.17|1.09|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.17||||2.17|1.37|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.17||||2.17|0.64|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.17||||2.17|1.19|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.17||||2.17|1.5|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.17||||2.17|1.09|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.17||||2.17|0.96|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.17||||2.17|0.64|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.17||||2.17|0.96|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.17||||2.17|0.64|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.17||||2.17|0.64|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.17||||2.17|1.5|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.17||||2.17|0.64|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|Self-pay|Self-pay|2.17||||2.17|0.76|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.17||||2.17|0.64|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.17||||2.17|0.64|1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.17||||2.17||1.5|0.64
70306|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ARIPIPRAZOLE 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.17||||2.17||1.5|0.64
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.62||||1.62|0.71|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.62||||1.62|0.48|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.62||||1.62|0.76|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.62||||1.62|0.81|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.62||||1.62|0.81|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.62||||1.62|1.02|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.62||||1.62|0.48|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.62||||1.62|0.89|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.62||||1.62|1.12|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.62||||1.62|0.81|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.62||||1.62|0.71|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.62||||1.62|0.48|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.62||||1.62|0.71|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.62||||1.62|0.48|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.62||||1.62|0.48|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.62||||1.62|1.12|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.62||||1.62|0.48|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|Self-pay|Self-pay|1.62||||1.62|0.57|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.62||||1.62|0.48|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.62||||1.62|0.48|1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.62||||1.62||1.12|0.48
70397|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.62||||1.62||1.12|0.48
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.65||||4.65|2.05|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.65||||4.65|1.38|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.65||||4.65|2.19|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.65||||4.65|2.33|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.65||||4.65|2.33|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.65||||4.65|2.93|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.65||||4.65|1.38|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.65||||4.65|2.56|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.65||||4.65|3.21|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.65||||4.65|2.33|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.65||||4.65|2.05|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.65||||4.65|1.38|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.65||||4.65|2.05|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.65||||4.65|1.38|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.65||||4.65|1.38|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.65||||4.65|3.21|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.65||||4.65|1.38|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|Self-pay|Self-pay|4.65||||4.65|1.63|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.65||||4.65|1.38|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.65||||4.65|1.38|3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.65||||4.65||3.21|1.38
70398|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|QUETIAPINE 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.65||||4.65||3.21|1.38
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|19.18||||19.18|8.46|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.18||||19.18|5.69|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|19.18||||19.18|9.01|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.18||||19.18|9.59|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.18||||19.18|9.59|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.18||||19.18|12.08|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.18||||19.18|5.69|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|19.18||||19.18|10.55|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|19.18||||19.18|13.23|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.18||||19.18|9.59|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.18||||19.18|8.46|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.18||||19.18|5.69|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.18||||19.18|8.46|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.18||||19.18|5.69|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.18||||19.18|5.69|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|19.18||||19.18|13.23|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.18||||19.18|5.69|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|Self-pay|Self-pay|19.18||||19.18|6.71|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.18||||19.18|5.69|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.18||||19.18|5.69|13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.18||||19.18||13.23|5.69
70472|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 24 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.18||||19.18||13.23|5.69
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AARP [1000]|AARP [100000]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AETNA [1015]|AETNA [101529]|55.8||||55.8|24.61|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|55.8||||55.8|16.54|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS [1155]|BCBS UTHCT [115568]|55.8||||55.8|26.23|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|55.8||||55.8|27.9|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|55.8||||55.8|27.9|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|55.8||||55.8|35.15|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|55.8||||55.8|16.54|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|CIGNA [1260]|CIGNA GWH [126023]|55.8||||55.8|30.69|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|GROUP PENSION ADMIN [1450]|GPA [145000]|55.8||||55.8|38.5|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|55.8||||55.8|27.9|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|55.8||||55.8|24.61|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|55.8||||55.8|16.54|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|55.8||||55.8|24.61|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|55.8||||55.8|16.54|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|55.8||||55.8|16.54|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|PHCS [1780]|PHCS MULTIPLAN [178000]|55.8||||55.8|38.5|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|55.8||||55.8|16.54|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|Self-pay|Self-pay|55.8||||55.8|19.53|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|55.8||||55.8|16.54|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|55.8||||55.8|16.54|38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|55.8||||55.8||38.5|16.54
70536|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 50 MCG/ACTUATION NASAL SPRAY,SUSPENSION|16 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|55.8||||55.8||38.5|16.54
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AARP [1000]|AARP [100000]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AETNA [1015]|AETNA [101529]|882.57||||882.57|398.4|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|882.57||||882.57|261.68|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BCBS UTHCT [115568]|882.57||||882.57|414.81|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|882.57||||882.57|0|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|882.57||||882.57|441.29|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|882.57||||882.57|556.02|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|882.57||||882.57|261.68|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|CIGNA [1260]|CIGNA GWH [126023]|882.57||||882.57|441.29|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|882.57||||882.57|608.97|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|882.57||||882.57|441.29|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|882.57||||882.57|398.4|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|882.57||||882.57|261.68|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|882.57||||882.57|398.4|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|882.57||||882.57|261.68|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|882.57||||882.57|261.68|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|882.57||||882.57|608.97|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|882.57||||882.57|261.68|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|Self-pay|Self-pay|882.57||||882.57|308.9|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|882.57||||882.57|261.68|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|882.57||||882.57|261.68|608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|882.57||||882.57||608.97|261.68
70693|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|INSULIN LISPRO PROTAMINE-LISPRO 100 UNIT/ML (75-25) SUBCUTANEOUS SUSP|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|882.57||||882.57||608.97|261.68
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.46||||2.46|1.08|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.46||||2.46|0.73|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.46||||2.46|1.16|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.46||||2.46|1.23|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.46||||2.46|1.23|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.46||||2.46|1.55|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.46||||2.46|0.73|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.46||||2.46|1.35|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.46||||2.46|1.7|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.46||||2.46|1.23|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.46||||2.46|1.08|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.46||||2.46|0.73|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.46||||2.46|1.08|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.46||||2.46|0.73|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.46||||2.46|0.73|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.46||||2.46|1.7|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.46||||2.46|0.73|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|Self-pay|Self-pay|2.46||||2.46|0.86|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.46||||2.46|0.73|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.46||||2.46|0.73|1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.46||||2.46||1.7|0.73
70773|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LEVETIRACETAM 1,000 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.46||||2.46||1.7|0.73
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|AARP [1000]|AARP [100000]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|0.53||||0.53|0.23|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.53||||0.53|0.16|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.53||||0.53|0.25|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.53||||0.53|0.27|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.53||||0.53|0.27|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.53||||0.53|0.33|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.53||||0.53|0.16|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.53||||0.53|0.29|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.53||||0.53|0.37|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.53||||0.53|0.27|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.53||||0.53|0.23|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.53||||0.53|0.16|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.53||||0.53|0.23|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.53||||0.53|0.16|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.53||||0.53|0.16|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.53||||0.53|0.37|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.53||||0.53|0.16|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|Self-pay|Self-pay|0.53||||0.53|0.19|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.53||||0.53|0.16|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.53||||0.53|0.16|0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.53||||0.53||0.37|0.16
70838|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 1 MG/ML ORAL SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.53||||0.53||0.37|0.16
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AARP [1000]|AARP [100000]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AETNA [1015]|AETNA [101529]|780||||780|343.98|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|780||||780|231.27|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|780||||780|366.6|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|780||||780|390|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|780||||780|390|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|780||||780|491.4|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|780||||780|231.27|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|780||||780|429|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|780||||780|538.2|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|780||||780|390|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|780||||780|343.98|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|780||||780|231.27|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|780||||780|343.98|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|780||||780|231.27|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|780||||780|231.27|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|780||||780|538.2|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|780||||780|231.27|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|Self-pay|Self-pay|780||||780|273|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|780||||780|231.27|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|780||||780|231.27|538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|780||||780||538.2|231.27
71000116|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I 1ST 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|780||||780||538.2|231.27
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|AARP [1000]|AARP [100000]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|AETNA [1015]|AETNA [101529]|130||||130|57.33|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|130||||130|38.55|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|BCBS [1155]|BCBS UTHCT [115568]|130||||130|61.1|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|130||||130|65|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|130||||130|65|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|130||||130|81.9|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|130||||130|38.55|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|CIGNA [1260]|CIGNA GWH [126023]|130||||130|71.5|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|130||||130|89.7|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|130||||130|65|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|130||||130|57.33|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|130||||130|38.55|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|130||||130|57.33|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|130||||130|38.55|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|130||||130|38.55|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|130||||130|89.7|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|130||||130|38.55|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|Self-pay|Self-pay|130||||130|45.5|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|130||||130|38.55|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|130||||130|38.55|89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|130||||130||89.7|38.55
71000117|EAP|0710 - RECOVERY ROOM-GENERAL|HC RECOVERY LVL I ADDL 30 MIN EA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|130||||130||89.7|38.55
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.67||||0.67|0.3|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.67||||0.67|0.2|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.67||||0.67|0.31|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.67||||0.67|0.34|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.67||||0.67|0.34|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.67||||0.67|0.42|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.67||||0.67|0.2|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.67||||0.67|0.37|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.67||||0.67|0.46|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.67||||0.67|0.34|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.67||||0.67|0.3|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.67||||0.67|0.2|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.67||||0.67|0.3|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.67||||0.67|0.2|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.67||||0.67|0.2|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.67||||0.67|0.46|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.67||||0.67|0.2|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|0.67||||0.67|0.23|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.67||||0.67|0.2|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.67||||0.67|0.2|0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.67||||0.67||0.46|0.2
716|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.67||||0.67||0.46|0.2
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.54||||0.54|0.24|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.54||||0.54|0.16|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.54||||0.54|0.25|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.54||||0.54|0.27|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.54||||0.54|0.27|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.54||||0.54|0.34|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.54||||0.54|0.16|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.54||||0.54|0.3|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.54||||0.54|0.37|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.54||||0.54|0.27|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.54||||0.54|0.24|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.54||||0.54|0.16|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.54||||0.54|0.24|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.54||||0.54|0.16|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.54||||0.54|0.16|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.54||||0.54|0.37|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.54||||0.54|0.16|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.54||||0.54|0.19|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.54||||0.54|0.16|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.54||||0.54|0.16|0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.54||||0.54||0.37|0.16
717|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.54||||0.54||0.37|0.16
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.29||||0.29|0.13|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.29||||0.29|0.09|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.29||||0.29|0.14|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.29||||0.29|0.15|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.29||||0.29|0.15|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.29||||0.29|0.18|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.29||||0.29|0.09|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.29||||0.29|0.16|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.29||||0.29|0.2|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.29||||0.29|0.15|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.29||||0.29|0.13|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.29||||0.29|0.09|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.29||||0.29|0.13|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.29||||0.29|0.09|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.29||||0.29|0.09|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.29||||0.29|0.2|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.29||||0.29|0.09|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.29||||0.29|0.1|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.29||||0.29|0.09|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.29||||0.29|0.09|0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.29||||0.29||0.2|0.09
718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATENOLOL 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.29||||0.29||0.2|0.09
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AARP [1000]|AARP [100000]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AETNA [1015]|AETNA [101529]|42.16||||42.16|18.59|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42.16||||42.16|12.5|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS [1155]|BCBS UTHCT [115568]|42.16||||42.16|19.82|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|42.16||||42.16|21.08|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|42.16||||42.16|21.08|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|42.16||||42.16|26.56|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|42.16||||42.16|12.5|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|CIGNA [1260]|CIGNA GWH [126023]|42.16||||42.16|23.19|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|GROUP PENSION ADMIN [1450]|GPA [145000]|42.16||||42.16|29.09|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|42.16||||42.16|21.08|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42.16||||42.16|18.59|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42.16||||42.16|12.5|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42.16||||42.16|18.59|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|42.16||||42.16|12.5|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|42.16||||42.16|12.5|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|PHCS [1780]|PHCS MULTIPLAN [178000]|42.16||||42.16|29.09|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42.16||||42.16|12.5|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|Self-pay|Self-pay|42.16||||42.16|14.76|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|42.16||||42.16|12.5|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|42.16||||42.16|12.5|29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42.16||||42.16||29.09|12.5
7224|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SILVER SULFADIAZINE 1 % TOPICAL CREAM|50 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|42.16||||42.16||29.09|12.5
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AARP [1000]|AARP [100000]|27.9||||27.9|13|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AETNA [1015]|AETNA [101529]|27.9||||27.9|14.4|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.9||||27.9|8.27|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BCBS UTHCT [115568]|27.9||||27.9|13.11|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.9||||27.9|0|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.9||||27.9|13.95|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.9||||27.9|17.58|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.9||||27.9|8.27|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|CIGNA [1260]|CIGNA GWH [126023]|27.9||||27.9|15.35|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.9||||27.9|19.25|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.9||||27.9|0.1|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.9||||27.9|14.4|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.9||||27.9|8.27|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.9||||27.9|14.4|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.9||||27.9|8.27|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.9||||27.9|8.27|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.9||||27.9|19.25|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.9||||27.9|8.27|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|Self-pay|Self-pay|27.9||||27.9|9.76|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.9||||27.9|8.27|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.9||||27.9|8.27|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.9||||27.9|13|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.9||||27.9|13|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.9||||27.9||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|AARP [1000]|AARP [100000]|28.2||||28.2|6.5|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.2||||28.2||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|AETNA [1015]|AETNA [101529]|28.2||||28.2|7.2|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.2||||28.2|8.36|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.2||||28.2||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.2||||28.2||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|BCBS [1155]|BCBS UTHCT [115568]|28.2||||28.2|13.25|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.2||||28.2|0|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.2||||28.2|14.1|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.2||||28.2|17.77|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.2||||28.2|8.36|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.2||||28.2||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|CIGNA [1260]|CIGNA GWH [126023]|28.2||||28.2|15.51|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|28.2||||28.2|19.46|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|28.2||||28.2|0.1|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.2||||28.2||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.2||||28.2|7.2|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.2||||28.2|8.36|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.2||||28.2||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.2||||28.2|7.2|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.2||||28.2|8.36|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|28.2||||28.2|8.36|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|28.2||||28.2|19.46|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.2||||28.2|8.36|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|Self-pay|Self-pay|28.2||||28.2|9.87|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|28.2||||28.2|8.36|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.2||||28.2|8.36|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.2||||28.2|6.5|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|28.2||||28.2||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|28.2||||28.2||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.2||||28.2|6.5|19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.2||||28.2||19.46|0.1
730|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 0.1 MG/ML INJECTION SYRINGE|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.2||||28.2||19.46|0.1
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|AARP [1000]|AARP [100000]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|AETNA [1015]|AETNA [101529]|33.52||||33.52|14.78|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.52||||33.52|9.94|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|BCBS [1155]|BCBS UTHCT [115568]|33.52||||33.52|15.75|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.52||||33.52|16.76|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.52||||33.52|16.76|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.52||||33.52|21.12|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.52||||33.52|9.94|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|CIGNA [1260]|CIGNA GWH [126023]|33.52||||33.52|18.44|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33.52||||33.52|23.13|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.52||||33.52|16.76|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.52||||33.52|14.78|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.52||||33.52|9.94|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.52||||33.52|14.78|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.52||||33.52|9.94|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.52||||33.52|9.94|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33.52||||33.52|23.13|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.52||||33.52|9.94|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|Self-pay|Self-pay|33.52||||33.52|11.73|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.52||||33.52|9.94|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.52||||33.52|9.94|23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.52||||33.52||23.13|9.94
7306|ERX|0250 - PHARMACY-GENERAL|SODIUM BICARBONATE 4.2 % (0.5 MEQ/ML) INTRAVENOUS SYRINGE (NEO/PED)|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.52||||33.52||23.13|9.94
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AARP [1000]|AARP [100000]|386||||386|100|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|386||||386|50.97|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AETNA [1015]|AETNA [101529]|386||||386|14.21|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|386||||386|114.45|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|386||||386|50.47|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|386||||386|50.47|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BCBS UTHCT [115568]|386||||386|181.42|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|386||||386|68.27|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|386||||386|193|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|386||||386|243.18|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|386||||386|114.45|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|386||||386|50.47|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|CIGNA [1260]|CIGNA GWH [126023]|386||||386|212.3|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|386||||386|266.34|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|386||||386|69.58|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|386||||386|54.05|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|386||||386|14.21|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|386||||386|114.45|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|386||||386|50.47|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|386||||386|14.21|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|386||||386|114.45|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|386||||386|114.45|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|386||||386|266.34|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|386||||386|114.45|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|Self-pay|Self-pay|386||||386|135.1|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|386||||386|114.45|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|386||||386|114.45|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|386||||386|100|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|386||||386|50.47|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|386||||386|50.47|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|386||||386|100|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|386||||386|50.47|266.34|14.21
73093005|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC EKG ROUTINE TRACING ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|386||||386|100.94|266.34|14.21
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|AARP [1000]|AARP [100000]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|AETNA [1015]|AETNA [101529]|182||||182|9.41|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182||||182|53.96|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|BCBS [1155]|BCBS UTHCT [115568]|182||||182|85.54|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182||||182|68.27|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182||||182|91|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182||||182|114.66|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182||||182|53.96|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|CIGNA [1260]|CIGNA GWH [126023]|182||||182|100.1|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|182||||182|125.58|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|182||||182|69.58|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182||||182|9.41|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182||||182|53.96|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182||||182|9.41|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182||||182|53.96|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|182||||182|53.96|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|182||||182|125.58|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182||||182|53.96|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|Self-pay|Self-pay|182||||182|63.7|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|182||||182|53.96|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182||||182|53.96|125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182||||182||125.58|9.41
73093041|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC RHYTHM TRACING ONLY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182||||182||125.58|9.41
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|AARP [1000]|AARP [100000]|92||||92|92|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|92||||92|30.99|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|AETNA [1015]|AETNA [101529]|92||||92|40.57|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|92||||92|27.28|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|92||||92|30.69|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|92||||92|30.69|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|BCBS [1155]|BCBS UTHCT [115568]|92||||92|43.24|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|92||||92|41.28|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|92||||92|46|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|92||||92|57.96|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|92||||92|27.28|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|92||||92|30.69|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|CIGNA [1260]|CIGNA GWH [126023]|92||||92|50.6|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|92||||92|63.48|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|92||||92|42.3|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|92||||92|32.86|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|92||||92|40.57|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|92||||92|27.28|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|92||||92|30.69|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|92||||92|40.57|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|92||||92|27.28|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|92||||92|27.28|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|92||||92|63.48|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|92||||92|27.28|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|Self-pay|Self-pay|92||||92|32.2|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|92||||92|27.28|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|92||||92|27.28|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|92||||92|92|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|92||||92|30.69|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|92||||92|30.69|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|92||||92|92|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|92||||92|30.69|92|27.28
73093242|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>48HR<7D RECORDING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|92||||92|61.37|92|27.28
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|AARP [1000]|AARP [100000]|151||||151|151|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|151||||151|50.97|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|AETNA [1015]|AETNA [101529]|151||||151|66.59|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|151||||151|44.77|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|151||||151|50.47|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|151||||151|50.47|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|BCBS [1155]|BCBS UTHCT [115568]|151||||151|70.97|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|151||||151|67.91|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|151||||151|75.5|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|151||||151|95.13|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|151||||151|44.77|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|151||||151|50.47|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|CIGNA [1260]|CIGNA GWH [126023]|151||||151|83.05|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|151||||151|104.19|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|151||||151|69.58|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|151||||151|54.05|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|151||||151|66.59|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|151||||151|44.77|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|151||||151|50.47|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|151||||151|66.59|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|151||||151|44.77|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|151||||151|44.77|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|151||||151|104.19|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|151||||151|44.77|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|Self-pay|Self-pay|151||||151|52.85|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|151||||151|44.77|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|151||||151|44.77|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|151||||151|151|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|151||||151|50.47|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|151||||151|50.47|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|151||||151|151|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|151||||151|50.47|151|44.77
73093246|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC EXTERNAL ECG REC>7D<15D RECORDING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|151||||151|100.94|151|44.77
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AARP [1000]|AARP [100000]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AETNA [1015]|AETNA [101529]|108||||108|14.81|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108||||108|32.02|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS [1155]|BCBS UTHCT [115568]|108||||108|50.76|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108||||108|46.04|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108||||108|54|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108||||108|68.04|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108||||108|32.02|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|CIGNA [1260]|CIGNA GWH [126023]|108||||108|59.4|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|GROUP PENSION ADMIN [1450]|GPA [145000]|108||||108|74.52|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|108||||108|46.44|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108||||108|14.81|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108||||108|32.02|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108||||108|14.81|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108||||108|32.02|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|108||||108|32.02|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|PHCS [1780]|PHCS MULTIPLAN [178000]|108||||108|74.52|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108||||108|32.02|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|Self-pay|Self-pay|108||||108|37.8|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|108||||108|32.02|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108||||108|32.02|74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108||||108||74.52|14.81
73093270|EAP|0730 - EKG/ECG (ELECTROCARDIOGRAM)-GENERAL|HC ECG EVENT <= 30 DAYS RECORDING|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108||||108||74.52|14.81
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.05||||0.05|0.02|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.05||||0.05|0.01|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.05||||0.05|0.02|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.05||||0.05|0.03|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.05||||0.05|0.03|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.05||||0.05|0.03|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.05||||0.05|0.01|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.05||||0.05|0.03|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.05||||0.05|0.03|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.05||||0.05|0.03|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.05||||0.05|0.02|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.05||||0.05|0.01|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.05||||0.05|0.02|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.05||||0.05|0.01|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.05||||0.05|0.01|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.05||||0.05|0.03|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.05||||0.05|0.01|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|Self-pay|Self-pay|0.05||||0.05|0.02|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.05||||0.05|0.01|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.05||||0.05|0.01|0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.05||||0.05||0.03|0.01
7313|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM BICARBONATE 650 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.05||||0.05||0.03|0.01
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5|6.98|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|6.12|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|3.41|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|6.12|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|6.12|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5|6.98|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5|6.98|10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|3.41
7318|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 0.45 % INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|3.41
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|AARP [1000]|AARP [100000]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|AETNA [1015]|AETNA [101529]|915||||915|43.03|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|915||||915|271.3|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|BCBS [1155]|BCBS UTHCT [115568]|915||||915|430.05|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|915||||915|128.15|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|915||||915|457.5|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|915||||915|576.45|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|915||||915|271.3|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|CIGNA [1260]|CIGNA GWH [126023]|915||||915|503.25|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|915||||915|631.35|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|915||||915|139.94|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|915||||915|43.03|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|915||||915|271.3|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|915||||915|43.03|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|915||||915|271.3|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|915||||915|271.3|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|915||||915|631.35|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|915||||915|271.3|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|Self-pay|Self-pay|915||||915|320.25|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|915||||915|271.3|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|915||||915|271.3|631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|915||||915||631.35|43.03
73193225|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN RECORDING UP TO 48 HRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|915||||915||631.35|43.03
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|AARP [1000]|AARP [100000]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|AETNA [1015]|AETNA [101529]|801||||801|61.06|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|801||||801|237.5|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|BCBS [1155]|BCBS UTHCT [115568]|801||||801|376.47|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|801||||801|128.15|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|801||||801|400.5|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|801||||801|504.63|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|801||||801|237.5|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|CIGNA [1260]|CIGNA GWH [126023]|801||||801|440.55|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|801||||801|552.69|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|801||||801|139.94|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|801||||801|61.06|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|801||||801|237.5|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|801||||801|61.06|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|801||||801|237.5|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|801||||801|237.5|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|801||||801|552.69|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|801||||801|237.5|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|Self-pay|Self-pay|801||||801|280.35|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|801||||801|237.5|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|801||||801|237.5|552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|801||||801||552.69|61.06
73193226|EAP|0731 - EKG/ECG (ELECTROCARDIOGRAM)-HOLTER MONITOR|HC HOLTER SCAN ANALYSIS UP TO 48 HRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|801||||801||552.69|61.06
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AARP [1000]|AARP [100000]|10.85||||10.85|4.88|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.85||||10.85||7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|10.85||||10.85|3.07|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.85||||10.85|3.22|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.85||||10.85||7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.85||||10.85||7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BCBS UTHCT [115568]|10.85||||10.85|5.1|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.85||||10.85|0|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.85||||10.85|5.43|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.85||||10.85|6.84|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.85||||10.85|3.22|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.85||||10.85||7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|CIGNA [1260]|CIGNA GWH [126023]|10.85||||10.85|5.97|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|10.85||||10.85|7.49|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.85||||10.85|1.71|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.85||||10.85||7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.85||||10.85|3.07|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.85||||10.85|3.22|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.85||||10.85||7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.85||||10.85|3.07|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.85||||10.85|3.22|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.85||||10.85|3.22|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|10.85||||10.85|7.49|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.85||||10.85|3.22|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|Self-pay|Self-pay|10.85||||10.85|3.8|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.85||||10.85|3.22|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.85||||10.85|3.22|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.85||||10.85|4.88|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.85||||10.85||7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.85||||10.85||7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.85||||10.85|4.88|7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.85||||10.85||7.49|1.71
7321|ERX|0258 - PHARMACY-IV SOLUTIONS|SODIUM CHLORIDE 3 % INTRAVENOUS INJECTION SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.85||||10.85||7.49|1.71
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AARP [1000]|AARP [100000]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AETNA [1015]|AETNA [101529]|0.4||||0.4|0.18|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.4||||0.4|0.12|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS [1155]|BCBS UTHCT [115568]|0.4||||0.4|0.19|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.4||||0.4|0.2|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.4||||0.4|0.2|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.4||||0.4|0.25|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.4||||0.4|0.12|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|CIGNA [1260]|CIGNA GWH [126023]|0.4||||0.4|0.22|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.4||||0.4|0.28|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.4||||0.4|0.2|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.4||||0.4|0.18|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.4||||0.4|0.12|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.4||||0.4|0.18|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.4||||0.4|0.12|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.4||||0.4|0.12|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.4||||0.4|0.28|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.4||||0.4|0.12|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|Self-pay|Self-pay|0.4||||0.4|0.14|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.4||||0.4|0.12|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.4||||0.4|0.12|0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.4||||0.4||0.28|0.12
7325|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 0.9 % FOR NEBULIZATION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.4||||0.4||0.28|0.12
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|AARP [1000]|AARP [100000]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|AETNA [1015]|AETNA [101529]|2.33||||2.33|1.03|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.33||||2.33|0.69|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|2.33||||2.33|1.1|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.33||||2.33|1.17|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.33||||2.33|1.17|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.33||||2.33|1.47|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.33||||2.33|0.69|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|2.33||||2.33|1.28|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.33||||2.33|1.61|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.33||||2.33|1.17|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.33||||2.33|1.03|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.33||||2.33|0.69|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.33||||2.33|1.03|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.33||||2.33|0.69|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.33||||2.33|0.69|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.33||||2.33|1.61|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.33||||2.33|0.69|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|Self-pay|Self-pay|2.33||||2.33|0.82|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.33||||2.33|0.69|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.33||||2.33|0.69|1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.33||||2.33||1.61|0.69
7326|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 10 % FOR NEBULIZATION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.33||||2.33||1.61|0.69
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AARP [1000]|AARP [100000]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AETNA [1015]|AETNA [101529]|1.03||||1.03|0.45|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.03||||1.03|0.31|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|1.03||||1.03|0.48|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.03||||1.03|0.52|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.03||||1.03|0.52|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.03||||1.03|0.65|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.03||||1.03|0.31|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|1.03||||1.03|0.57|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.03||||1.03|0.71|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.03||||1.03|0.52|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.03||||1.03|0.45|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.03||||1.03|0.31|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.03||||1.03|0.45|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.03||||1.03|0.31|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.03||||1.03|0.31|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.03||||1.03|0.71|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.03||||1.03|0.31|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|Self-pay|Self-pay|1.03||||1.03|0.36|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.03||||1.03|0.31|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.03||||1.03|0.31|0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.03||||1.03||0.71|0.31
7327|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 3 % FOR NEBULIZATION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.03||||1.03||0.71|0.31
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AARP [1000]|AARP [100000]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.25||||0.25|0.11|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.25||||0.25|0.07|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.25||||0.25|0.12|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.25||||0.25|0.13|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.25||||0.25|0.13|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.25||||0.25|0.16|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.25||||0.25|0.07|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.25||||0.25|0.14|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.25||||0.25|0.17|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.25||||0.25|0.13|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.25||||0.25|0.11|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.25||||0.25|0.07|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.25||||0.25|0.11|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.25||||0.25|0.07|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.25||||0.25|0.07|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.25||||0.25|0.17|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.25||||0.25|0.07|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|Self-pay|Self-pay|0.25||||0.25|0.09|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.25||||0.25|0.07|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.25||||0.25|0.07|0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.25||||0.25||0.17|0.07
7328|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SODIUM CHLORIDE 1 GRAM TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.25||||0.25||0.17|0.07
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|AARP [1000]|AARP [100000]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|AETNA [1015]|AETNA [101529]|63||||63|63|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63||||63|18.68|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|BCBS [1155]|BCBS UTHCT [115568]|63||||63|29.61|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63||||63|46.04|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63||||63|31.5|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63||||63|39.69|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63||||63|18.68|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|CIGNA [1260]|CIGNA GWH [126023]|63||||63|34.65|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63||||63|43.47|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63||||63|46.44|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63||||63|63|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63||||63|18.68|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63||||63|63|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63||||63|18.68|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63||||63|18.68|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63||||63|43.47|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63||||63|18.68|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|Self-pay|Self-pay|63||||63|22.05|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63||||63|18.68|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63||||63|18.68|63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63||||63||63|18.68
73293293|EAP|0732 - EKG/ECG (ELECTROCARDIOGRAM)-TELEMETRY|HC PM PHONE R-STRIP DEVICE EVAL <=90DAYS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63||||63||63|18.68
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|19.47||||19.47|6.5|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.47||||19.47||13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|19.47||||19.47|7.2|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.47||||19.47|5.77|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.47||||19.47||13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.47||||19.47||13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|19.47||||19.47|9.15|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.47||||19.47|0|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.47||||19.47|9.74|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.47||||19.47|12.27|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.47||||19.47|5.77|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.47||||19.47||13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|19.47||||19.47|10.71|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.47||||19.47|13.43|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.47||||19.47|0.1|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.47||||19.47||13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.47||||19.47|7.2|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.47||||19.47|5.77|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.47||||19.47||13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.47||||19.47|7.2|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.47||||19.47|5.77|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.47||||19.47|5.77|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.47||||19.47|13.43|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.47||||19.47|5.77|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|Self-pay|Self-pay|19.47||||19.47|6.81|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.47||||19.47|5.77|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.47||||19.47|5.77|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.47||||19.47|6.5|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.47||||19.47||13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.47||||19.47||13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.47||||19.47|6.5|13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.47||||19.47||13.43|0.1
734|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ATROPINE 1 MG/ML INJECTION SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.47||||19.47||13.43|0.1
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|50.04||||50.04|22.07|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|50.04||||50.04|14.84|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|50.04||||50.04|23.52|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|50.04||||50.04|25.02|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|50.04||||50.04|25.02|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|50.04||||50.04|31.53|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|50.04||||50.04|14.84|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|50.04||||50.04|27.52|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|50.04||||50.04|34.53|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|50.04||||50.04|25.02|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|50.04||||50.04|22.07|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|50.04||||50.04|14.84|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|50.04||||50.04|22.07|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|50.04||||50.04|14.84|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|50.04||||50.04|14.84|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|50.04||||50.04|34.53|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|50.04||||50.04|14.84|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|50.04||||50.04|17.51|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|50.04||||50.04|14.84|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|50.04||||50.04|14.84|34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|50.04||||50.04||34.53|14.84
7351|ERX|0250 - PHARMACY-GENERAL|SODIUM PHOSPHATE 3 MMOL/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|50.04||||50.04||34.53|14.84
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|138.02||||138.02|60.87|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|138.02||||138.02|40.92|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|138.02||||138.02|64.87|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|138.02||||138.02|69.01|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|138.02||||138.02|69.01|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|138.02||||138.02|86.95|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|138.02||||138.02|40.92|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|138.02||||138.02|75.91|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|138.02||||138.02|95.23|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|138.02||||138.02|69.01|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|138.02||||138.02|60.87|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|138.02||||138.02|40.92|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|138.02||||138.02|60.87|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|138.02||||138.02|40.92|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|138.02||||138.02|40.92|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|138.02||||138.02|95.23|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|138.02||||138.02|40.92|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|Self-pay|Self-pay|138.02||||138.02|48.31|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|138.02||||138.02|40.92|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|138.02||||138.02|40.92|95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|138.02||||138.02||95.23|40.92
7359|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFACETAMIDE SODIUM 10 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|138.02||||138.02||95.23|40.92
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|AARP [1000]|AARP [100000]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|AETNA [1015]|AETNA [101529]|118.7||||118.7|52.35|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|118.7||||118.7|35.19|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|BCBS [1155]|BCBS UTHCT [115568]|118.7||||118.7|55.79|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|118.7||||118.7|59.35|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|118.7||||118.7|59.35|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|118.7||||118.7|74.78|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|118.7||||118.7|35.19|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|CIGNA [1260]|CIGNA GWH [126023]|118.7||||118.7|65.29|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|118.7||||118.7|81.9|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|118.7||||118.7|59.35|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|118.7||||118.7|52.35|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|118.7||||118.7|35.19|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|118.7||||118.7|52.35|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|118.7||||118.7|35.19|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|118.7||||118.7|35.19|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|118.7||||118.7|81.9|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|118.7||||118.7|35.19|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|Self-pay|Self-pay|118.7||||118.7|41.54|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|118.7||||118.7|35.19|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|118.7||||118.7|35.19|81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|118.7||||118.7||81.9|35.19
736|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ATROPINE 1 % EYE DROPS|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|118.7||||118.7||81.9|35.19
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|AARP [1000]|AARP [100000]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|AETNA [1015]|AETNA [101529]|2151||||2151|606.72|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2151||||2151|637.77|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|BCBS [1155]|BCBS UTHCT [115568]|2151||||2151|1010.97|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2151||||2151|462.36|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2151||||2151|1075.5|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2151||||2151|1355.13|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2151||||2151|637.77|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|CIGNA [1260]|CIGNA GWH [126023]|2151||||2151|875|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2151||||2151|1484.19|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2151||||2151|609.73|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2151||||2151|606.72|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2151||||2151|637.77|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2151||||2151|606.72|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2151||||2151|637.77|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2151||||2151|637.77|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2151||||2151|1484.19|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2151||||2151|637.77|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|Self-pay|Self-pay|2151||||2151|752.85|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2151||||2151|637.77|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2151||||2151|637.77|1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2151||||2151||1484.19|462.36
74095805|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC MULTIPLE SLEEP LATENCY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2151||||2151||1484.19|462.36
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|AARP [1000]|AARP [100000]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|AETNA [1015]|AETNA [101529]|850||||850|148.37|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|850||||850|252.03|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|BCBS [1155]|BCBS UTHCT [115568]|850||||850|399.5|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|850||||850|134.86|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|850||||850|425|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|850||||850|535.5|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|850||||850|252.03|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|CIGNA [1260]|CIGNA GWH [126023]|850||||850|850|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|850||||850|586.5|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|850||||850|174.44|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|850||||850|148.37|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|850||||850|252.03|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|850||||850|148.37|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|850||||850|252.03|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|850||||850|252.03|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|850||||850|586.5|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|850||||850|252.03|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|Self-pay|Self-pay|850||||850|297.5|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|850||||850|252.03|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|850||||850|252.03|850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|850||||850||850|134.86
74095806|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC SLEEP STUDY UNATTENDED&RESP EFFT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|850||||850||850|134.86
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|AARP [1000]|AARP [100000]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|AETNA [1015]|AETNA [101529]|3781||||3781|827.69|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3781||||3781|1121.07|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|BCBS [1155]|BCBS UTHCT [115568]|3781||||3781|1777.07|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3781||||3781|625.68|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3781||||3781|1890.5|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3781||||3781|2382.03|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3781||||3781|1121.07|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|CIGNA [1260]|CIGNA GWH [126023]|3781||||3781|875|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|3781||||3781|2608.89|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3781||||3781|1149.78|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3781||||3781|827.69|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3781||||3781|1121.07|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3781||||3781|827.69|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3781||||3781|1121.07|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|3781||||3781|1121.07|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|3781||||3781|2608.89|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3781||||3781|1121.07|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|Self-pay|Self-pay|3781||||3781|1323.35|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3781||||3781|1121.07|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3781||||3781|1121.07|2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3781||||3781||2608.89|625.68
74095810|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+ PARAM AGE>=6YRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3781||||3781||2608.89|625.68
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|AARP [1000]|AARP [100000]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|AETNA [1015]|AETNA [101529]|4488||||4488|869.88|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4488||||4488|1330.69|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|BCBS [1155]|BCBS UTHCT [115568]|4488||||4488|2109.36|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4488||||4488|658.52|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4488||||4488|2244|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4488||||4488|2827.44|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4488||||4488|1330.69|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|CIGNA [1260]|CIGNA GWH [126023]|4488||||4488|875|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|4488||||4488|3096.72|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4488||||4488|1149.78|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4488||||4488|869.88|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4488||||4488|1330.69|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4488||||4488|869.88|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4488||||4488|1330.69|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|4488||||4488|1330.69|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|4488||||4488|3096.72|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4488||||4488|1330.69|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|Self-pay|Self-pay|4488||||4488|1570.8|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4488||||4488|1330.69|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4488||||4488|1330.69|3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4488||||4488||3096.72|658.52
74095811|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG 4+PARA W/CPAP/BILVL VENT AGE>=6YRS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4488||||4488||3096.72|658.52
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AARP [1000]|AARP [100000]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|6.51||||6.51|2.87|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.51||||6.51|1.93|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|6.51||||6.51|3.06|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.51||||6.51|3.26|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.51||||6.51|3.26|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.51||||6.51|4.1|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.51||||6.51|1.93|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|6.51||||6.51|3.58|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.51||||6.51|4.49|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.51||||6.51|3.26|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.51||||6.51|2.87|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.51||||6.51|1.93|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.51||||6.51|2.87|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.51||||6.51|1.93|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.51||||6.51|1.93|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.51||||6.51|4.49|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.51||||6.51|1.93|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|Self-pay|Self-pay|6.51||||6.51|2.28|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.51||||6.51|1.93|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.51||||6.51|1.93|4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.51||||6.51||4.49|1.93
7413|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SORBITOL 70 % SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.51||||6.51||4.49|1.93
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.56||||0.56|0.25|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.56||||0.56|0.17|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.56||||0.56|0.26|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.56||||0.56|0.28|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.56||||0.56|0.28|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.56||||0.56|0.35|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.56||||0.56|0.17|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.56||||0.56|0.31|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.56||||0.56|0.39|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.56||||0.56|0.28|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.56||||0.56|0.25|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.56||||0.56|0.17|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.56||||0.56|0.25|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.56||||0.56|0.17|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.56||||0.56|0.17|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.56||||0.56|0.39|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.56||||0.56|0.17|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.56||||0.56|0.2|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.56||||0.56|0.17|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.56||||0.56|0.17|0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.56||||0.56||0.39|0.17
7437|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SPIRONOLACTONE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.56||||0.56||0.39|0.17
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|9.3||||9.3|4.1|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.3||||9.3|2.76|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|9.3||||9.3|4.37|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.3||||9.3|4.65|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.3||||9.3|4.65|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.3||||9.3|5.86|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.3||||9.3|2.76|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|9.3||||9.3|5.12|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.3||||9.3|6.42|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.3||||9.3|4.65|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.3||||9.3|4.1|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.3||||9.3|2.76|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.3||||9.3|4.1|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.3||||9.3|2.76|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.3||||9.3|2.76|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.3||||9.3|6.42|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.3||||9.3|2.76|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|Self-pay|Self-pay|9.3||||9.3|3.25|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.3||||9.3|2.76|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.3||||9.3|2.76|6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.3||||9.3||6.42|2.76
7485|ERX|0250 - PHARMACY-GENERAL|WATER FOR IRRIGATION, STERILE SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.3||||9.3||6.42|2.76
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|AARP [1000]|AARP [100000]|1715||||1715|361|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1715||||1715|726.9|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|AETNA [1015]|AETNA [101529]|1715||||1715|1715|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1715||||1715|508.5|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1715||||1715|719.7|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1715||||1715|719.7|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|BCBS [1155]|BCBS UTHCT [115568]|1715||||1715||1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1715||||1715|108.1|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1715||||1715||1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1715||||1715||1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1715||||1715|508.5|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1715||||1715|719.7|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|CIGNA [1260]|CIGNA GWH [126023]|1715||||1715|0|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1715||||1715|1097.6|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1715||||1715|992.06|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1715||||1715|770.8|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1715||||1715|1715|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1715||||1715|508.5|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1715||||1715|719.7|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1715||||1715|1715|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1715||||1715|508.5|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1715||||1715|508.5|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1715||||1715|1097.6|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1715||||1715|508.5|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|Self-pay|Self-pay|1715||||1715|600.25|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1715||||1715|508.5|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1715||||1715|508.5|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1715||||1715|361|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1715||||1715|719.7|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1715||||1715|719.7|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1715||||1715|361|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1715||||1715|719.7|1715|108.1
75000104|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC SIGMOIDOSCOPY FLEXI CA SCREEN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1715||||1715|1439.4|1715|108.1
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|AARP [1000]|AARP [100000]|2018||||2018|361|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018|726.9|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|AETNA [1015]|AETNA [101529]|2018||||2018|2018|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018|719.7|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018|719.7|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018|893|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018|553.78|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018|1191|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018|1191|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018|719.7|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018|825|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|992.06|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018|770.8|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018|2018|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018|719.7|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018|2018|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|Self-pay|Self-pay|2018||||2018|706.3|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|598.34|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018|361|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018|719.7|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018|719.7|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018|361|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018|719.7|2018|361
75000105|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREENING HIGH RISK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018|1439.4|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|AARP [1000]|AARP [100000]|2018||||2018|361|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2018||||2018|726.9|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|AETNA [1015]|AETNA [101529]|2018||||2018|2018|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2018||||2018|598.34|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2018||||2018|719.7|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2018||||2018|719.7|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|BCBS [1155]|BCBS UTHCT [115568]|2018||||2018|893|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2018||||2018|553.78|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2018||||2018|1191|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2018||||2018|1191|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2018||||2018|598.34|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2018||||2018|719.7|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|CIGNA [1260]|CIGNA GWH [126023]|2018||||2018|825|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2018||||2018|1291.52|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2018||||2018|992.06|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2018||||2018|770.8|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2018||||2018|2018|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2018||||2018|598.34|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2018||||2018|719.7|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2018||||2018|2018|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2018||||2018|598.34|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2018||||2018|598.34|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2018||||2018|1291.52|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2018||||2018|598.34|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|Self-pay|Self-pay|2018||||2018|706.3|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2018||||2018|598.34|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2018||||2018|598.34|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2018||||2018|361|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2018||||2018|719.7|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2018||||2018|719.7|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2018||||2018|361|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2018||||2018|719.7|2018|361
75000121|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC COLONOSCOPY SCREEN NOT HIGH RISK|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2018||||2018|1439.4|2018|361
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AARP [1000]|AARP [100000]|116.25||||116.25|84.38|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116.25||||116.25||92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AETNA [1015]|AETNA [101529]|116.25||||116.25|92.66|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116.25||||116.25|34.47|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116.25||||116.25||92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116.25||||116.25||92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|BCBS [1155]|BCBS UTHCT [115568]|116.25||||116.25|54.64|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116.25||||116.25|0|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116.25||||116.25|58.13|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116.25||||116.25|73.24|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116.25||||116.25|34.47|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116.25||||116.25||92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|CIGNA [1260]|CIGNA GWH [126023]|116.25||||116.25|63.94|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|116.25||||116.25|80.21|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116.25||||116.25|41.33|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116.25||||116.25||92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116.25||||116.25|92.66|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116.25||||116.25|34.47|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116.25||||116.25||92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116.25||||116.25|92.66|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116.25||||116.25|34.47|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|116.25||||116.25|34.47|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|116.25||||116.25|80.21|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116.25||||116.25|34.47|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|Self-pay|Self-pay|116.25||||116.25|40.69|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116.25||||116.25|34.47|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116.25||||116.25|34.47|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116.25||||116.25|84.38|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116.25||||116.25||92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116.25||||116.25||92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116.25||||116.25|84.38|92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116.25||||116.25||92.66|34.47
7508|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|STREPTOMYCIN 1 GRAM INTRAMUSCULAR SOLUTION|0.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116.25||||116.25||92.66|34.47
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|AARP [1000]|AARP [100000]|1063||||1063|119|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1063||||1063|446.75|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|AETNA [1015]|AETNA [101529]|1063||||1063|1063|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1063||||1063|315.18|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1063||||1063|442.33|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1063||||1063|442.33|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|BCBS [1155]|BCBS UTHCT [115568]|1063||||1063|1350|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1063||||1063|136.6|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1063||||1063|1682|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1063||||1063|1800|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1063||||1063|315.18|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1063||||1063|442.33|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|CIGNA [1260]|CIGNA GWH [126023]|1063||||1063|0|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1063||||1063|680.32|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1063||||1063|609.73|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1063||||1063|473.74|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1063||||1063|1063|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1063||||1063|315.18|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1063||||1063|442.33|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1063||||1063|1063|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1063||||1063|315.18|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1063||||1063|315.18|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1063||||1063|680.32|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1063||||1063|315.18|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|Self-pay|Self-pay|1063||||1063|372.05|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1063||||1063|315.18|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1063||||1063|315.18|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1063||||1063|119|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1063||||1063|442.33|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1063||||1063|442.33|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1063||||1063|119|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1063||||1063|442.33|1800|119
75091010|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESPOHAGUS MOTILITY STUDYMANOMETRY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1063||||1063|884.66|1800|119
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|AARP [1000]|AARP [100000]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|AETNA [1015]|AETNA [101529]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1063||||1063|315.18|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|BCBS [1155]|BCBS UTHCT [115568]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1063||||1063|199.65|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1063||||1063|315.18|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|CIGNA [1260]|CIGNA GWH [126023]|1063||||1063|0|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1063||||1063|680.32|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1063||||1063|609.73|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1063||||1063|315.18|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1063||||1063|315.18|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1063||||1063|315.18|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1063||||1063|680.32|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1063||||1063|315.18|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|Self-pay|Self-pay|1063||||1063|372.05|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1063||||1063|315.18|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1063||||1063|315.18|680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1063||||1063||680.32|199.65
75091020|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GASTRIC MOTILITY STUDIES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1063||||1063||680.32|199.65
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|AARP [1000]|AARP [100000]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|AETNA [1015]|AETNA [101529]|1063||||1063|1063|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1063||||1063|315.18|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|BCBS [1155]|BCBS UTHCT [115568]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1063||||1063|495.64|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1063||||1063|315.18|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|CIGNA [1260]|CIGNA GWH [126023]|1063||||1063|0|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1063||||1063|680.32|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1063||||1063|609.73|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1063||||1063|1063|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1063||||1063|315.18|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1063||||1063|1063|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1063||||1063|315.18|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1063||||1063|315.18|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1063||||1063|680.32|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1063||||1063|315.18|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|Self-pay|Self-pay|1063||||1063|372.05|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1063||||1063|315.18|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1063||||1063|315.18|1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1063||||1063||1063|315.18
75091035|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GE REFLUX TEST MUCOSAL PH ELECTRO|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1063||||1063||1063|315.18
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|AARP [1000]|AARP [100000]|1998||||1998|567|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1998||||1998|741.5|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|AETNA [1015]|AETNA [101529]|1998||||1998|1998|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1998||||1998|761.55|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1998||||1998|734.16|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1998||||1998|734.16|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|BCBS [1155]|BCBS UTHCT [115568]|1998||||1998||1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1998||||1998|904.14|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1998||||1998||1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1998||||1998||1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1998||||1998|761.55|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1998||||1998|734.16|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|CIGNA [1260]|CIGNA GWH [126023]|1998||||1998|0|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1998||||1998|1278.72|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1998||||1998|1012|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1998||||1998|786.28|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1998||||1998|1998|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1998||||1998|761.55|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1998||||1998|734.16|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1998||||1998|1998|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1998||||1998|761.55|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1998||||1998|761.55|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1998||||1998|1278.72|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1998||||1998|761.55|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|Self-pay|Self-pay|1998||||1998|699.3|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1998||||1998|761.55|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1998||||1998|761.55|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1998||||1998|567|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1998||||1998|734.16|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1998||||1998|734.16|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1998||||1998|567|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1998||||1998|734.16|1998|567
75091110|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC GI CAPSULE ENDOSCOPY ESOPH-ILEUM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1998||||1998|1468.32|1998|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|AARP [1000]|AARP [100000]|2343||||2343|567|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2343||||2343|741.5|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|AETNA [1015]|AETNA [101529]|2343||||2343|2343|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2343||||2343|761.55|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2343||||2343|734.16|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2343||||2343|734.16|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|BCBS [1155]|BCBS UTHCT [115568]|2343||||2343||2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2343||||2343|862.99|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2343||||2343||2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2343||||2343||2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2343||||2343|761.55|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2343||||2343|734.16|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|CIGNA [1260]|CIGNA GWH [126023]|2343||||2343|0|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2343||||2343|1499.52|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2343||||2343|1012|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2343||||2343|786.28|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2343||||2343|2343|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2343||||2343|761.55|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2343||||2343|734.16|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2343||||2343|2343|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2343||||2343|761.55|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2343||||2343|761.55|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2343||||2343|1499.52|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2343||||2343|761.55|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|Self-pay|Self-pay|2343||||2343|820.05|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2343||||2343|761.55|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2343||||2343|761.55|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2343||||2343|567|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2343||||2343|734.16|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2343||||2343|734.16|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2343||||2343|567|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2343||||2343|734.16|2343|567
75091111|EAP|0750 - GASTROINTESTINAL (GI) SERVICES-GENERAL|HC ESOPHAGEAL CAPSULE ENDOSCOPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2343||||2343|1468.32|2343|567
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|19.44||||19.44|8.57|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.44||||19.44|5.76|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|19.44||||19.44|9.14|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.44||||19.44|9.72|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.44||||19.44|9.72|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.44||||19.44|12.25|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.44||||19.44|5.76|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|19.44||||19.44|10.69|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|19.44||||19.44|13.41|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.44||||19.44|9.72|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.44||||19.44|8.57|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.44||||19.44|5.76|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.44||||19.44|8.57|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.44||||19.44|5.76|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.44||||19.44|5.76|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|19.44||||19.44|13.41|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.44||||19.44|5.76|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|19.44||||19.44|6.8|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.44||||19.44|5.76|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.44||||19.44|5.76|13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.44||||19.44||13.41|5.76
7556|ERX|0250 - PHARMACY-GENERAL|SULFAMETHOXAZOLE 400 MG-TRIMETHOPRIM 80 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.44||||19.44||13.41|5.76
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AARP [1000]|AARP [100000]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AETNA [1015]|AETNA [101529]|6.15||||6.15|2.71|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.15||||6.15|1.82|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|6.15||||6.15|2.89|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.15||||6.15|3.08|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.15||||6.15|3.08|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.15||||6.15|3.87|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.15||||6.15|1.82|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|6.15||||6.15|3.38|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.15||||6.15|4.24|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.15||||6.15|3.08|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.15||||6.15|2.71|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.15||||6.15|1.82|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.15||||6.15|2.71|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.15||||6.15|1.82|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.15||||6.15|1.82|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.15||||6.15|4.24|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.15||||6.15|1.82|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|Self-pay|Self-pay|6.15||||6.15|2.15|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.15||||6.15|1.82|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.15||||6.15|1.82|4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.15||||6.15||4.24|1.82
7563|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SULFASALAZINE 500 MG TABLET,DELAYED RELEASE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.15||||6.15||4.24|1.82
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|AARP [1000]|AARP [100000]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|AETNA [1015]|AETNA [101529]|186||||186|82.03|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|186||||186|55.15|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|BCBS [1155]|BCBS UTHCT [115568]|186||||186|87.42|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|186||||186|32.84|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|186||||186|93|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|186||||186|117.18|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|186||||186|55.15|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|CIGNA [1260]|CIGNA GWH [126023]|186||||186|102.3|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|GROUP PENSION ADMIN [1450]|GPA [145000]|186||||186|128.34|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|186||||186|93.59|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|186||||186|82.03|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|186||||186|55.15|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|186||||186|82.03|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|186||||186|55.15|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|186||||186|55.15|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|PHCS [1780]|PHCS MULTIPLAN [178000]|186||||186|128.34|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|186||||186|55.15|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|Self-pay|Self-pay|186||||186|65.1|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|186||||186|55.15|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|186||||186|55.15|128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|186||||186||128.34|32.84
76100296|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC VISIT TO DETERM LDCT ELIG|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|186||||186||128.34|32.84
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|AARP [1000]|AARP [100000]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|AETNA [1015]|AETNA [101529]|1131||||1131|498.77|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1131||||1131|335.34|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|BCBS [1155]|BCBS UTHCT [115568]|1131||||1131|531.57|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1131||||1131|814.32|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1131||||1131|565.5|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1131||||1131|712.53|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1131||||1131|335.34|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|CIGNA [1260]|CIGNA GWH [126023]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1131||||1131|780.39|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1131||||1131|655.21|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1131||||1131|498.77|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1131||||1131|335.34|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1131||||1131|498.77|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1131||||1131|335.34|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1131||||1131|335.34|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1131||||1131|780.39|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1131||||1131|335.34|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|Self-pay|Self-pay|1131||||1131|395.85|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1131||||1131|335.34|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1131||||1131|335.34|814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1131||||1131||814.32|335.34
76105271|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC APP SKIN SUB LC T/A/L 25CM2 ADULT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1131||||1131||814.32|335.34
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|AARP [1000]|AARP [100000]|200.04||||200.04|90.02|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|200.04||||200.04|50.97|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|AETNA [1015]|AETNA [101529]|200.04||||200.04|40.27|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|200.04||||200.04|59.31|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|200.04||||200.04|50.47|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|200.04||||200.04|50.47|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|BCBS [1155]|BCBS UTHCT [115568]|200.04||||200.04|94.02|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|200.04||||200.04|68.27|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|200.04||||200.04|100.02|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|200.04||||200.04|126.03|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|200.04||||200.04|59.31|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|200.04||||200.04|50.47|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|CIGNA [1260]|CIGNA GWH [126023]|200.04||||200.04|110.02|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|GROUP PENSION ADMIN [1450]|GPA [145000]|200.04||||200.04|138.03|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|200.04||||200.04|69.58|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|200.04||||200.04|54.05|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|200.04||||200.04|40.27|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|200.04||||200.04|59.31|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|200.04||||200.04|50.47|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|200.04||||200.04|40.27|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|200.04||||200.04|59.31|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|200.04||||200.04|59.31|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|PHCS [1780]|PHCS MULTIPLAN [178000]|200.04||||200.04|138.03|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|200.04||||200.04|59.31|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|Self-pay|Self-pay|200.04||||200.04|70.01|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|200.04||||200.04|59.31|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|200.04||||200.04|59.31|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|200.04||||200.04|90.02|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|200.04||||200.04|50.47|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|200.04||||200.04|50.47|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|200.04||||200.04|90.02|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|200.04||||200.04|50.47|138.03|40.27
76196523|EAP|0761 - SPECIALTY SERVICES-TREATMENT ROOM|HC IRRIG IMPLANT VENOUS ACCESS DEV|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|200.04||||200.04|100.94|138.03|40.27
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|AARP [1000]|AARP [100000]|300||||300|300|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|AETNA [1015]|AETNA [101529]|300||||300|147|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|88.95|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|154.56|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|88.95|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|300|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|150|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|147|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|88.95|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|147|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|88.95|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|88.95|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|88.95|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|Self-pay|Self-pay|300||||300|105|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|88.95|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|88.95|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|300|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|300|300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||300|88.95
76200002|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RADIOLOGY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|AARP [1000]|AARP [100000]|300||||300|300|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|AETNA [1015]|AETNA [101529]|300||||300|147|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|88.95|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|154.56|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|88.95|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|300|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|150|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|147|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|88.95|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|147|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|88.95|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|88.95|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|88.95|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|Self-pay|Self-pay|300||||300|105|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|88.95|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|88.95|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|300|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|300|300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||300|88.95
76200003|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - G.I.|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|AARP [1000]|AARP [100000]|300||||300|300|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|AETNA [1015]|AETNA [101529]|300||||300|147|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|88.95|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|154.56|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|88.95|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|300|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|150|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|147|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|88.95|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|147|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|88.95|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|88.95|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|88.95|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|Self-pay|Self-pay|300||||300|105|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|88.95|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|88.95|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|300|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|300|300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||300|88.95
76200004|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - CARDIOLOGY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|AARP [1000]|AARP [100000]|300||||300|300|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|AETNA [1015]|AETNA [101529]|300||||300|147|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|88.95|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|154.56|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|88.95|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|300|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|150|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|147|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|88.95|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|147|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|88.95|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|88.95|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|88.95|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|Self-pay|Self-pay|300||||300|105|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|88.95|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|88.95|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|300|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|300|300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||300|88.95
76200005|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE-OUT - RESPIRATORY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|AARP [1000]|AARP [100000]|300||||300|300|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|AETNA [1015]|AETNA [101529]|300||||300|147|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|88.95|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|154.56|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|88.95|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|300|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|150|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|147|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|88.95|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|147|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|88.95|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|88.95|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|88.95|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|Self-pay|Self-pay|300||||300|105|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|88.95|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|88.95|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|300|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|300|300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||300|88.95
76200006|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION CARVE OUT - BLOOD ADMIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|AARP [1000]|AARP [100000]|300||||300|300|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|AETNA [1015]|AETNA [101529]|300||||300|147|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|300||||300|88.95|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|BCBS [1155]|BCBS UTHCT [115568]|300||||300|141|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|300||||300|154.56|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|300||||300|150|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|300||||300|189|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|300||||300|88.95|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|CIGNA [1260]|CIGNA GWH [126023]|300||||300|300|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|300||||300|207|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|300||||300|150|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|300||||300|147|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|300||||300|88.95|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|300||||300|147|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|300||||300|88.95|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|300||||300|88.95|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|300||||300|207|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|300||||300|88.95|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|Self-pay|Self-pay|300||||300|105|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|300||||300|88.95|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|300||||300|88.95|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|300||||300|300|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|300||||300|300|300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|300||||300||300|88.95
76200378|EAP|0762 - SPECIALTY SERVICES-OBSERVATION HOURS|HC OBSERVATION SERVICES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|300||||300||300|88.95
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.21||||0.21|0.09|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.21||||0.21|0.06|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.21||||0.21|0.1|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.21||||0.21|0.11|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.21||||0.21|0.11|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.21||||0.21|0.13|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.21||||0.21|0.06|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.21||||0.21|0.12|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.21||||0.21|0.14|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.21||||0.21|0.11|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.21||||0.21|0.09|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.21||||0.21|0.06|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.21||||0.21|0.09|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.21||||0.21|0.06|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.21||||0.21|0.06|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.21||||0.21|0.14|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.21||||0.21|0.06|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.21||||0.21|0.07|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.21||||0.21|0.06|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.21||||0.21|0.06|0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.21||||0.21||0.14|0.06
76335|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETYLCYSTEINE 600 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.21||||0.21||0.14|0.06
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AARP [1000]|AARP [100000]|1162.5||||1162.5|1162.5|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1162.5||||1162.5|174.28|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AETNA [1015]|AETNA [101529]|1162.5||||1162.5|513.6|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1162.5||||1162.5|344.68|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1162.5||||1162.5|172.55|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1162.5||||1162.5|172.55|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BCBS UTHCT [115568]|1162.5||||1162.5|546.38|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1162.5||||1162.5|0|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1162.5||||1162.5|581.25|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1162.5||||1162.5|732.38|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1162.5||||1162.5|344.68|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1162.5||||1162.5|172.55|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|CIGNA [1260]|CIGNA GWH [126023]|1162.5||||1162.5|581.25|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1162.5||||1162.5|802.13|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1162.5||||1162.5|4.29|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1162.5||||1162.5|172.55|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1162.5||||1162.5|513.6|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1162.5||||1162.5|344.68|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1162.5||||1162.5|172.55|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1162.5||||1162.5|513.6|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1162.5||||1162.5|344.68|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|1162.5||||1162.5|344.68|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1162.5||||1162.5|802.13|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1162.5||||1162.5|344.68|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|Self-pay|Self-pay|1162.5||||1162.5|406.87|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1162.5||||1162.5|344.68|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1162.5||||1162.5|344.68|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1162.5||||1162.5|1162.5|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1162.5||||1162.5|172.55|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1162.5||||1162.5|172.55|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1162.5||||1162.5|1162.5|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1162.5||||1162.5|172.55|1162.5|4.29
76364|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DECITABINE 50 MG INTRAVENOUS SOLUTION|50 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1162.5||||1162.5|345.1|1162.5|4.29
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|42.63||||42.63|18.8|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42.63||||42.63|12.64|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|42.63||||42.63|20.04|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|42.63||||42.63|21.32|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|42.63||||42.63|21.32|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|42.63||||42.63|26.86|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|42.63||||42.63|12.64|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|42.63||||42.63|23.45|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|42.63||||42.63|29.41|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|42.63||||42.63|21.32|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42.63||||42.63|18.8|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42.63||||42.63|12.64|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42.63||||42.63|18.8|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|42.63||||42.63|12.64|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|42.63||||42.63|12.64|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|42.63||||42.63|29.41|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42.63||||42.63|12.64|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|42.63||||42.63|14.92|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|42.63||||42.63|12.64|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|42.63||||42.63|12.64|29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42.63||||42.63||29.41|12.64
76480|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|RASAGILINE 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|42.63||||42.63||29.41|12.64
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|AARP [1000]|AARP [100000]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|AETNA [1015]|AETNA [101529]|691.68||||691.68|305.03|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|691.68||||691.68|205.08|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|BCBS [1155]|BCBS UTHCT [115568]|691.68||||691.68|325.09|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|691.68||||691.68|0|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|691.68||||691.68|345.84|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|691.68||||691.68|435.76|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|691.68||||691.68|205.08|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|CIGNA [1260]|CIGNA GWH [126023]|691.68||||691.68|345.84|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|691.68||||691.68|477.26|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|691.68||||691.68|345.84|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|691.68||||691.68|305.03|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|691.68||||691.68|205.08|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|691.68||||691.68|305.03|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|691.68||||691.68|205.08|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|691.68||||691.68|205.08|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|691.68||||691.68|477.26|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|691.68||||691.68|205.08|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|Self-pay|Self-pay|691.68||||691.68|242.09|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|691.68||||691.68|205.08|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|691.68||||691.68|205.08|477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|691.68||||691.68||477.26|205.08
76518|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOSTER VACCINE LIVE (PF) 19,400 UNIT/0.65 ML SUBCUTANEOUS SUSPENSION|0.65 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|691.68||||691.68||477.26|205.08
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AARP [1000]|AARP [100000]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|29.33||||29.33|12.93|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.33||||29.33|8.7|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BCBS UTHCT [115568]|29.33||||29.33|13.79|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.33||||29.33|14.67|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.33||||29.33|14.67|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.33||||29.33|18.48|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.33||||29.33|8.7|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|CIGNA [1260]|CIGNA GWH [126023]|29.33||||29.33|16.13|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|29.33||||29.33|20.24|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29.33||||29.33|14.67|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.33||||29.33|12.93|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.33||||29.33|8.7|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.33||||29.33|12.93|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.33||||29.33|8.7|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|29.33||||29.33|8.7|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|29.33||||29.33|20.24|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.33||||29.33|8.7|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|Self-pay|Self-pay|29.33||||29.33|10.27|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29.33||||29.33|8.7|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.33||||29.33|8.7|20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.33||||29.33||20.24|8.7
76720|ERX|0250 - PHARMACY-GENERAL|SODIUM HYPOCHLORITE 0.125 % SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.33||||29.33||20.24|8.7
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|AARP [1000]|AARP [100000]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|AETNA [1015]|AETNA [101529]|53.94||||53.94|23.79|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|53.94||||53.94|15.99|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|BCBS [1155]|BCBS UTHCT [115568]|53.94||||53.94|25.35|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|53.94||||53.94|26.97|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|53.94||||53.94|26.97|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|53.94||||53.94|33.98|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|53.94||||53.94|15.99|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|CIGNA [1260]|CIGNA GWH [126023]|53.94||||53.94|29.67|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|53.94||||53.94|37.22|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|53.94||||53.94|26.97|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|53.94||||53.94|23.79|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|53.94||||53.94|15.99|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|53.94||||53.94|23.79|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|53.94||||53.94|15.99|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|53.94||||53.94|15.99|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|53.94||||53.94|37.22|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|53.94||||53.94|15.99|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|Self-pay|Self-pay|53.94||||53.94|18.88|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|53.94||||53.94|15.99|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|53.94||||53.94|15.99|37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|53.94||||53.94||37.22|15.99
76913|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM CHLORIDE 20 MEQ/15 ML ORAL LIQUID|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|53.94||||53.94||37.22|15.99
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|AARP [1000]|AARP [100000]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|AETNA [1015]|AETNA [101529]|6.59||||6.59|2.91|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.59||||6.59|1.95|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|BCBS [1155]|BCBS UTHCT [115568]|6.59||||6.59|3.1|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.59||||6.59|3.3|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.59||||6.59|3.3|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.59||||6.59|4.15|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.59||||6.59|1.95|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|CIGNA [1260]|CIGNA GWH [126023]|6.59||||6.59|3.62|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|GROUP PENSION ADMIN [1450]|GPA [145000]|6.59||||6.59|4.55|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.59||||6.59|3.3|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.59||||6.59|2.91|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.59||||6.59|1.95|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.59||||6.59|2.91|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.59||||6.59|1.95|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.59||||6.59|1.95|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|PHCS [1780]|PHCS MULTIPLAN [178000]|6.59||||6.59|4.55|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.59||||6.59|1.95|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|Self-pay|Self-pay|6.59||||6.59|2.31|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.59||||6.59|1.95|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.59||||6.59|1.95|4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.59||||6.59||4.55|1.95
76971|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METHYL SALICYLATE 15 %-MENTHOL 10 % TOPICAL CREAM|85 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.59||||6.59||4.55|1.95
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|AARP [1000]|AARP [100000]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|AETNA [1015]|AETNA [101529]|0.33||||0.33|0.15|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.33||||0.33|0.1|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BCBS UTHCT [115568]|0.33||||0.33|0.16|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.33||||0.33|0.17|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.33||||0.33|0.17|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.33||||0.33|0.21|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.33||||0.33|0.1|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|CIGNA [1260]|CIGNA GWH [126023]|0.33||||0.33|0.18|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|GROUP PENSION ADMIN [1450]|GPA [145000]|0.33||||0.33|0.23|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.33||||0.33|0.17|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.33||||0.33|0.15|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.33||||0.33|0.1|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.33||||0.33|0.15|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.33||||0.33|0.1|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.33||||0.33|0.1|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|PHCS [1780]|PHCS MULTIPLAN [178000]|0.33||||0.33|0.23|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.33||||0.33|0.1|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|Self-pay|Self-pay|0.33||||0.33|0.12|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.33||||0.33|0.1|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.33||||0.33|0.1|0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.33||||0.33||0.23|0.1
76974|ERX|0250 - PHARMACY-GENERAL|GLYCERIN (CHILD) RECTAL SUPPOSITORY|1 suppository|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.33||||0.33||0.23|0.1
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|AARP [1000]|AARP [100000]|94||||94|0|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94||||94||93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|AETNA [1015]|AETNA [101529]|94||||94|41.45|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94||||94|27.87|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94||||94||93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|94||||94||93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|BCBS [1155]|BCBS UTHCT [115568]|94||||94|44.18|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|94||||94|34.59|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94||||94|47|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|94||||94|59.22|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|94||||94|27.87|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94||||94||93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|CIGNA [1260]|CIGNA GWH [126023]|94||||94|51.7|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|94||||94|64.86|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|94||||94|93.59|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|94||||94||93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94||||94|41.45|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94||||94|27.87|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94||||94||93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94||||94|41.45|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|94||||94|27.87|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|94||||94|27.87|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|94||||94|64.86|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94||||94|27.87|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|Self-pay|Self-pay|94||||94|32.9|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|94||||94|27.87|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|94||||94|27.87|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94||||94|0|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|94||||94||93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|94||||94||93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94||||94|0|93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94||||94||93.59|27.87
77000101|EAP|0770 - PREVENTIVE CARE SERVICES-GENERAL|HC RCANCER SCREEN PELVIC & BREAST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|94||||94||93.59|27.87
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|AARP [1000]|AARP [100000]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|AETNA [1015]|AETNA [101529]|37.2||||37.2|16.41|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|37.2||||37.2|11.03|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|BCBS [1155]|BCBS UTHCT [115568]|37.2||||37.2|17.48|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|37.2||||37.2|18.6|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|37.2||||37.2|18.6|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|37.2||||37.2|23.44|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|37.2||||37.2|11.03|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|CIGNA [1260]|CIGNA GWH [126023]|37.2||||37.2|20.46|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|37.2||||37.2|25.67|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|37.2||||37.2|18.6|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|37.2||||37.2|16.41|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|37.2||||37.2|11.03|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|37.2||||37.2|16.41|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|37.2||||37.2|11.03|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|37.2||||37.2|11.03|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|37.2||||37.2|25.67|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|37.2||||37.2|11.03|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|Self-pay|Self-pay|37.2||||37.2|13.02|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|37.2||||37.2|11.03|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|37.2||||37.2|11.03|25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|37.2||||37.2||25.67|11.03
77005|ERX|0250 - PHARMACY-GENERAL|MORPHINE SULFATE 1 MG/ML 30 ML PCA SYRINGE (1 HOUR LOCKOUT) REPACK|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|37.2||||37.2||25.67|11.03
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|AARP [1000]|AARP [100000]|116||||116|0|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116|36.63|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|AETNA [1015]|AETNA [101529]|116||||116|51.16|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116|34.39|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116|36.27|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116|36.27|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|58|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116|34.39|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116|36.27|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|63.8|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|19.38|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116|38.85|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|51.16|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116|34.39|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116|36.27|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|51.16|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116|34.39|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116|34.39|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116|34.39|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|Self-pay|Self-pay|116||||116|40.6|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116|34.39|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116|34.39|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116|0|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116|36.27|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116|36.27|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116|0|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116|36.27|80.04|19.38
77100001|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 1ST DOSE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116|72.54|80.04|19.38
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|AARP [1000]|AARP [100000]|116||||116|0|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116||||116|36.63|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|AETNA [1015]|AETNA [101529]|116||||116|51.16|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116||||116|34.39|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116||||116|36.27|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116||||116|36.27|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|BCBS [1155]|BCBS UTHCT [115568]|116||||116|54.52|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116||||116|58|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116||||116|58|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116||||116|73.08|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116||||116|34.39|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116||||116|36.27|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|CIGNA [1260]|CIGNA GWH [126023]|116||||116|63.8|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|116||||116|80.04|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116||||116|31.88|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116||||116|38.85|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116||||116|51.16|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116||||116|34.39|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116||||116|36.27|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116||||116|51.16|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116||||116|34.39|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|116||||116|34.39|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|116||||116|80.04|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116||||116|34.39|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|Self-pay|Self-pay|116||||116|40.6|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116||||116|34.39|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116||||116|34.39|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116||||116|0|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116||||116|36.27|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116||||116|36.27|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116||||116|0|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116||||116|36.27|80.04|31.88
77100002|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMN SARSCOV2 30MCG/0.3ML DIL RCON 2ND DOSE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116||||116|72.54|80.04|31.88
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AARP [1000]|AARP [100000]|71||||71|0|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71||||71|36.63|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AETNA [1015]|AETNA [101529]|71||||71|31.31|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71||||71|21.05|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71||||71|36.27|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71||||71|36.27|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BCBS UTHCT [115568]|71||||71|33.37|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71||||71|28.9|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71||||71|35.5|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71||||71|44.73|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71||||71|21.05|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71||||71|36.27|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|CIGNA [1260]|CIGNA GWH [126023]|71||||71|39.05|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71||||71|48.99|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71||||71|77.46|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71||||71|38.85|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71||||71|31.31|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71||||71|21.05|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71||||71|36.27|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71||||71|31.31|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71||||71|21.05|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|71||||71|21.05|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71||||71|48.99|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71||||71|21.05|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|Self-pay|Self-pay|71||||71|24.85|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71||||71|21.05|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71||||71|21.05|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71||||71|0|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71||||71|36.27|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71||||71|36.27|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71||||71|0|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71||||71|36.27|77.46|21.05
77100008|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ INFLUENZA VACCINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71||||71|72.54|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AARP [1000]|AARP [100000]|71||||71|0|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71||||71|36.63|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AETNA [1015]|AETNA [101529]|71||||71|31.31|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71||||71|21.05|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71||||71|36.27|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71||||71|36.27|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BCBS UTHCT [115568]|71||||71|33.37|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71||||71|58.23|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71||||71|35.5|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71||||71|44.73|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71||||71|21.05|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71||||71|36.27|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|CIGNA [1260]|CIGNA GWH [126023]|71||||71|39.05|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|71||||71|48.99|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71||||71|77.46|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71||||71|38.85|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71||||71|31.31|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71||||71|21.05|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71||||71|36.27|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71||||71|31.31|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71||||71|21.05|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|71||||71|21.05|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|71||||71|48.99|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71||||71|21.05|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|Self-pay|Self-pay|71||||71|24.85|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71||||71|21.05|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71||||71|21.05|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71||||71|0|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71||||71|36.27|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71||||71|36.27|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71||||71|0|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71||||71|36.27|77.46|21.05
77100009|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ PNEUMOCOCCAL VACCINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71||||71|72.54|77.46|21.05
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AARP [1000]|AARP [100000]|101.67||||101.67|0|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|101.67||||101.67||70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AETNA [1015]|AETNA [101529]|101.67||||101.67|44.84|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|101.67||||101.67|30.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|101.67||||101.67||70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|101.67||||101.67||70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BCBS UTHCT [115568]|101.67||||101.67|47.78|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|101.67||||101.67|63.05|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|101.67||||101.67|50.84|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|101.67||||101.67|64.05|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|101.67||||101.67|30.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|101.67||||101.67||70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|CIGNA [1260]|CIGNA GWH [126023]|101.67||||101.67|55.92|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|101.67||||101.67|70.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|101.67||||101.67|50|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|101.67||||101.67||70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|101.67||||101.67|44.84|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|101.67||||101.67|30.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|101.67||||101.67||70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|101.67||||101.67|44.84|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|101.67||||101.67|30.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|101.67||||101.67|30.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|101.67||||101.67|70.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|101.67||||101.67|30.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|Self-pay|Self-pay|101.67||||101.67|35.58|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|101.67||||101.67|30.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|101.67||||101.67|30.15|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|101.67||||101.67|0|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|101.67||||101.67||70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|101.67||||101.67||70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|101.67||||101.67|0|70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|101.67||||101.67||70.15|30.15
77100010|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC INJ HEPATITIS B VACCINE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|101.67||||101.67||70.15|30.15
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|AARP [1000]|AARP [100000]|120||||120|0|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|120||||120|36.63|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|AETNA [1015]|AETNA [101529]|120||||120|52.92|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|120||||120|35.58|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|120||||120|36.27|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|120||||120|36.27|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|BCBS [1155]|BCBS UTHCT [115568]|120||||120|56.4|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|120||||120|60|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|120||||120|60|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|120||||120|75.6|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|120||||120|35.58|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|120||||120|36.27|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|CIGNA [1260]|CIGNA GWH [126023]|120||||120|66|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|GROUP PENSION ADMIN [1450]|GPA [145000]|120||||120|82.8|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|120||||120|60|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|120||||120|38.85|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|120||||120|52.92|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|120||||120|35.58|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|120||||120|36.27|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|120||||120|52.92|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|120||||120|35.58|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|120||||120|35.58|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|PHCS [1780]|PHCS MULTIPLAN [178000]|120||||120|82.8|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|120||||120|35.58|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|Self-pay|Self-pay|120||||120|42|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|120||||120|35.58|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|120||||120|35.58|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|120||||120|0|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|120||||120|36.27|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|120||||120|36.27|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|120||||120|0|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|120||||120|36.27|82.8|35.58
77100030|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMM ADMIN SARSCOV2 30MCG/0.3ML 3RD DOSE PFIZER|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|120||||120|72.54|82.8|35.58
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.6||||0.6|0.26|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.6||||0.6|0.18|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.6||||0.6|0.28|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.6||||0.6|0.3|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.6||||0.6|0.3|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.6||||0.6|0.38|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.6||||0.6|0.18|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.6||||0.6|0.33|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.6||||0.6|0.41|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.6||||0.6|0.3|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.6||||0.6|0.26|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.6||||0.6|0.18|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.6||||0.6|0.26|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.6||||0.6|0.18|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.6||||0.6|0.18|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.6||||0.6|0.41|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.6||||0.6|0.18|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.6||||0.6|0.21|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.6||||0.6|0.18|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.6||||0.6|0.18|0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.6||||0.6||0.41|0.18
7711|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TAMOXIFEN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.6||||0.6||0.41|0.18
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|AARP [1000]|AARP [100000]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|AETNA [1015]|AETNA [101529]|1654.29||||1654.29|729.54|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1654.29||||1654.29|490.5|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|BCBS [1155]|BCBS UTHCT [115568]|1654.29||||1654.29|777.52|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1654.29||||1654.29|827.15|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1654.29||||1654.29|827.15|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1654.29||||1654.29|1042.2|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1654.29||||1654.29|490.5|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|CIGNA [1260]|CIGNA GWH [126023]|1654.29||||1654.29|909.86|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1654.29||||1654.29|1141.46|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1654.29||||1654.29|827.15|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1654.29||||1654.29|729.54|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1654.29||||1654.29|490.5|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1654.29||||1654.29|729.54|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1654.29||||1654.29|490.5|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|1654.29||||1654.29|490.5|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1654.29||||1654.29|1141.46|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1654.29||||1654.29|490.5|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|Self-pay|Self-pay|1654.29||||1654.29|579|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1654.29||||1654.29|490.5|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1654.29||||1654.29|490.5|1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1654.29||||1654.29||1141.46|490.5
77175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|FLUTICASONE PROPIONATE 230 MCG-SALMETEROL 21 MCG/ACTUATION HFA INHALER|12 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1654.29||||1654.29||1141.46|490.5
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|AARP [1000]|AARP [100000]|517||||517|0|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|517||||517|56.76|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|AETNA [1015]|AETNA [101529]|517||||517|228|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|517||||517|153.29|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|517||||517|56.2|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|517||||517|56.2|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|BCBS [1155]|BCBS UTHCT [115568]|517||||517|242.99|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|517||||517|71|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|517||||517|258.5|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|517||||517|325.71|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|517||||517|153.29|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|517||||517|56.2|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|CIGNA [1260]|CIGNA GWH [126023]|517||||517|284.35|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|517||||517|356.73|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|517||||517|77.46|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|517||||517|60.19|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|517||||517|228|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|517||||517|153.29|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|517||||517|56.2|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|517||||517|228|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|517||||517|153.29|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|517||||517|153.29|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|517||||517|356.73|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|517||||517|153.29|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|Self-pay|Self-pay|517||||517|180.95|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|517||||517|153.29|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|517||||517|153.29|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|517||||517|0|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|517||||517|56.2|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|517||||517|56.2|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|517||||517|0|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|517||||517|56.2|356.73|56.2
77190471|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN ONE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|517||||517|112.4|356.73|56.2
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|AARP [1000]|AARP [100000]|86||||86|0|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|86||||86||59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|AETNA [1015]|AETNA [101529]|86||||86|37.93|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|86||||86|25.5|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|86||||86||59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|86||||86||59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|BCBS [1155]|BCBS UTHCT [115568]|86||||86|40.42|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|86||||86|15.76|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|86||||86|43|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|86||||86|54.18|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|86||||86|25.5|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|86||||86||59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|CIGNA [1260]|CIGNA GWH [126023]|86||||86|47.3|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|86||||86|59.34|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|86||||86|43|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|86||||86||59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86||||86|37.93|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|86||||86|25.5|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|86||||86||59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|86||||86|37.93|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|86||||86|25.5|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|86||||86|25.5|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|86||||86|59.34|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|86||||86|25.5|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|Self-pay|Self-pay|86||||86|30.1|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|86||||86|25.5|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|86||||86|25.5|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|86||||86|0|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|86||||86||59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|86||||86||59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|86||||86|0|59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|86||||86||59.34|15.76
77190472|EAP|0771 - PREVENTIVE CARE SERVICES-VACCINE ADMINISTRA|HC IMMUNIZATION ADMIN EA ADDL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|86||||86||59.34|15.76
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|9.3||||9.3|9.3|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.3||||9.3|2.76|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|9.3||||9.3|4.37|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.3||||9.3|0|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.3||||9.3|4.65|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.3||||9.3|5.86|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.3||||9.3|2.76|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|9.3||||9.3|5.12|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.3||||9.3|6.42|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.3||||9.3|0.15|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.3||||9.3|9.3|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.3||||9.3|2.76|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.3||||9.3|9.3|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.3||||9.3|2.76|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.3||||9.3|2.76|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.3||||9.3|6.42|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.3||||9.3|2.76|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|9.3||||9.3|3.25|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.3||||9.3|2.76|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.3||||9.3|2.76|9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.3||||9.3||9.3|0.15
77195|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.3||||9.3||9.3|0.15
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|51.34||||51.34|22.64|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.34||||51.34|15.22|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|51.34||||51.34|24.13|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.34||||51.34|25.67|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.34||||51.34|25.67|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.34||||51.34|32.34|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.34||||51.34|15.22|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|51.34||||51.34|28.24|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|51.34||||51.34|35.42|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|51.34||||51.34|25.67|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.34||||51.34|22.64|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.34||||51.34|15.22|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.34||||51.34|22.64|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.34||||51.34|15.22|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|51.34||||51.34|15.22|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|51.34||||51.34|35.42|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.34||||51.34|15.22|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|Self-pay|Self-pay|51.34||||51.34|17.97|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|51.34||||51.34|15.22|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.34||||51.34|15.22|35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.34||||51.34||35.42|15.22
77617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|SITAGLIPTIN 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.34||||51.34||35.42|15.22
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|579.7||||579.7|252|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|579.7||||579.7|171.88|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|579.7||||579.7|272.46|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|579.7||||579.7|0|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|579.7||||579.7|289.85|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|579.7||||579.7|365.21|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|579.7||||579.7|171.88|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|579.7||||579.7|289.85|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|579.7||||579.7|399.99|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|579.7||||579.7|1.36|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|579.7||||579.7|252|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|579.7||||579.7|171.88|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|579.7||||579.7|252|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|579.7||||579.7|171.88|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|579.7||||579.7|171.88|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|579.7||||579.7|399.99|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|579.7||||579.7|171.88|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|579.7||||579.7|202.89|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|579.7||||579.7|171.88|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|579.7||||579.7|171.88|399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|579.7||||579.7||399.99|1.36
77685|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MICAFUNGIN 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|579.7||||579.7||399.99|1.36
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AARP [1000]|AARP [100000]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|16.74||||16.74|7.38|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.74||||16.74|4.96|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|16.74||||16.74|7.87|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.74||||16.74|8.37|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.74||||16.74|8.37|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.74||||16.74|10.55|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.74||||16.74|4.96|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|16.74||||16.74|9.21|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.74||||16.74|11.55|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.74||||16.74|8.37|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.74||||16.74|7.38|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.74||||16.74|4.96|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.74||||16.74|7.38|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.74||||16.74|4.96|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.74||||16.74|4.96|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.74||||16.74|11.55|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.74||||16.74|4.96|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|Self-pay|Self-pay|16.74||||16.74|5.86|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.74||||16.74|4.96|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.74||||16.74|4.96|11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.74||||16.74||11.55|4.96
77725|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|METOCLOPRAMIDE 5 MG/5 ML ORAL SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.74||||16.74||11.55|4.96
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|AARP [1000]|AARP [100000]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|AETNA [1015]|AETNA [101529]|33.29||||33.29|14.68|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.29||||33.29|9.87|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|BCBS [1155]|BCBS UTHCT [115568]|33.29||||33.29|15.65|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.29||||33.29|16.65|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.29||||33.29|16.65|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.29||||33.29|20.97|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.29||||33.29|9.87|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|CIGNA [1260]|CIGNA GWH [126023]|33.29||||33.29|18.31|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|33.29||||33.29|22.97|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.29||||33.29|16.65|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.29||||33.29|14.68|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.29||||33.29|9.87|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.29||||33.29|14.68|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.29||||33.29|9.87|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.29||||33.29|9.87|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|33.29||||33.29|22.97|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.29||||33.29|9.87|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|Self-pay|Self-pay|33.29||||33.29|11.65|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.29||||33.29|9.87|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.29||||33.29|9.87|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|118 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.29||||33.29||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AARP [1000]|AARP [100000]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AETNA [1015]|AETNA [101529]|1.76||||1.76|0.78|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.76||||1.76|0.52|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BCBS UTHCT [115568]|1.76||||1.76|0.83|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.76||||1.76|0.88|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.76||||1.76|0.88|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.76||||1.76|1.11|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.76||||1.76|0.52|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|CIGNA [1260]|CIGNA GWH [126023]|1.76||||1.76|0.97|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.76||||1.76|1.21|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.76||||1.76|0.88|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.76||||1.76|0.78|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.76||||1.76|0.52|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.76||||1.76|0.78|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.76||||1.76|0.52|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.76||||1.76|0.52|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.76||||1.76|1.21|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.76||||1.76|0.52|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|Self-pay|Self-pay|1.76||||1.76|0.62|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.76||||1.76|0.52|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.76||||1.76|0.52|22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.76||||1.76||22.97|0.52
78003|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CODEINE 10 MG-GUAIFENESIN 100 MG/5 ML ORAL LIQUID|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.76||||1.76||22.97|0.52
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|28.43||||28.43|12.54|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.43||||28.43|8.43|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|28.43||||28.43|13.36|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.43||||28.43|14.22|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.43||||28.43|14.22|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.43||||28.43|17.91|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.43||||28.43|8.43|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|28.43||||28.43|15.64|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|28.43||||28.43|19.62|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|28.43||||28.43|14.22|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.43||||28.43|12.54|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.43||||28.43|8.43|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.43||||28.43|12.54|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.43||||28.43|8.43|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|28.43||||28.43|8.43|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|28.43||||28.43|19.62|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.43||||28.43|8.43|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|28.43||||28.43|9.95|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|28.43||||28.43|8.43|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.43||||28.43|8.43|19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.43||||28.43||19.62|8.43
78064|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 3 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|28.43||||28.43|12.54|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|28.43||||28.43|8.43|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|28.43||||28.43|13.36|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|28.43||||28.43|14.22|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|28.43||||28.43|14.22|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|28.43||||28.43|17.91|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|28.43||||28.43|8.43|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|28.43||||28.43|15.64|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|28.43||||28.43|19.62|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|28.43||||28.43|14.22|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|28.43||||28.43|12.54|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|28.43||||28.43|8.43|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|28.43||||28.43|12.54|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|28.43||||28.43|8.43|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|28.43||||28.43|8.43|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|28.43||||28.43|19.62|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|28.43||||28.43|8.43|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|28.43||||28.43|9.95|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|28.43||||28.43|8.43|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|28.43||||28.43|8.43|19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|28.43||||28.43||19.62|8.43
78065|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 6 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|28.43||||28.43||19.62|8.43
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|51.21||||51.21|22.58|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.21||||51.21|15.18|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|51.21||||51.21|24.07|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.21||||51.21|25.61|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.21||||51.21|25.61|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.21||||51.21|32.26|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.21||||51.21|15.18|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|51.21||||51.21|28.17|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|51.21||||51.21|35.33|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|51.21||||51.21|25.61|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.21||||51.21|22.58|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.21||||51.21|15.18|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.21||||51.21|22.58|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.21||||51.21|15.18|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|51.21||||51.21|15.18|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|51.21||||51.21|35.33|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.21||||51.21|15.18|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|51.21||||51.21|17.92|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|51.21||||51.21|15.18|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.21||||51.21|15.18|35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.21||||51.21||35.33|15.18
78066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PALIPERIDONE ER 9 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.21||||51.21||35.33|15.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|AARP [1000]|AARP [100000]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|AETNA [1015]|AETNA [101529]|7.35||||7.35|3.24|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|7.35||||7.35|2.18|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BCBS UTHCT [115568]|7.35||||7.35|3.45|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|7.35||||7.35|3.68|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|7.35||||7.35|3.68|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|7.35||||7.35|4.63|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|7.35||||7.35|2.18|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|CIGNA [1260]|CIGNA GWH [126023]|7.35||||7.35|4.04|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|7.35||||7.35|5.07|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|7.35||||7.35|3.68|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|7.35||||7.35|3.24|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|7.35||||7.35|2.18|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|7.35||||7.35|3.24|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|7.35||||7.35|2.18|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|7.35||||7.35|2.18|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|7.35||||7.35|5.07|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|7.35||||7.35|2.18|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|Self-pay|Self-pay|7.35||||7.35|2.57|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|7.35||||7.35|2.18|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|7.35||||7.35|2.18|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|7.35||||7.35||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|AARP [1000]|AARP [100000]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|231.68||||231.68|102.17|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|231.68||||231.68|68.69|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|BCBS [1155]|BCBS UTHCT [115568]|231.68||||231.68|108.89|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|231.68||||231.68|115.84|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|231.68||||231.68|115.84|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|231.68||||231.68|145.96|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|231.68||||231.68|68.69|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|CIGNA [1260]|CIGNA GWH [126023]|231.68||||231.68|127.42|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|231.68||||231.68|159.86|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|231.68||||231.68|115.84|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|231.68||||231.68|102.17|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|231.68||||231.68|68.69|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|231.68||||231.68|102.17|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|231.68||||231.68|68.69|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|231.68||||231.68|68.69|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|231.68||||231.68|159.86|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|231.68||||231.68|68.69|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|Self-pay|Self-pay|231.68||||231.68|81.09|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|231.68||||231.68|68.69|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|231.68||||231.68|68.69|159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|231.68||||231.68||159.86|2.18
7821|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THEOPHYLLINE 80 MG/15 ML ORAL SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|231.68||||231.68||159.86|2.18
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|AARP [1000]|AARP [100000]|651||||651|433|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|651||||651|93.83|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|AETNA [1015]|AETNA [101529]|651||||651|261.6|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|651||||651|193.02|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|651||||651|92.9|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|651||||651|92.9|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|651||||651|305.97|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|651||||651|0|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|651||||651|325.5|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|651||||651|410.13|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|651||||651|193.02|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|651||||651|92.9|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|651||||651|325.5|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|651||||651|449.19|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|651||||651|1.14|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|651||||651|92.9|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|651||||651|261.6|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|651||||651|193.02|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|651||||651|92.9|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|651||||651|261.6|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|651||||651|193.02|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|651||||651|193.02|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|651||||651|449.19|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|651||||651|193.02|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|Self-pay|Self-pay|651||||651|227.85|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|651||||651|193.02|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|651||||651|193.02|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|651||||651|433|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|651||||651|92.9|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|651||||651|92.9|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|651||||651|433|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|651||||651|92.9|449.19|1.14
78420|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AZACITIDINE 100 MG SOLUTION FOR INJECTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|651||||651|185.8|449.19|1.14
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|30.85||||30.85|13.25|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|30.85||||30.85|9.15|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|30.85||||30.85|14.5|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|30.85||||30.85|0|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|30.85||||30.85|15.43|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|30.85||||30.85|19.44|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|30.85||||30.85|9.15|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|30.85||||30.85|16.97|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|30.85||||30.85|21.29|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|30.85||||30.85|3.18|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|30.85||||30.85|13.25|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|30.85||||30.85|9.15|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|30.85||||30.85|13.25|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|30.85||||30.85|9.15|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|30.85||||30.85|9.15|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|30.85||||30.85|21.29|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|30.85||||30.85|9.15|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|30.85||||30.85|10.8|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|30.85||||30.85|9.15|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|30.85||||30.85|9.15|21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|30.85||||30.85||21.29|3.18
7876|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|30.85||||30.85||21.29|3.18
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|3.9||||3.9|1.72|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.9||||3.9|1.16|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|3.9||||3.9|1.83|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.9||||3.9|1.95|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.9||||3.9|1.95|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.9||||3.9|2.46|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.9||||3.9|1.16|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|3.9||||3.9|2.15|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|3.9||||3.9|2.69|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.9||||3.9|1.95|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.9||||3.9|1.72|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.9||||3.9|1.16|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.9||||3.9|1.72|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.9||||3.9|1.16|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.9||||3.9|1.16|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|3.9||||3.9|2.69|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.9||||3.9|1.16|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|Self-pay|Self-pay|3.9||||3.9|1.36|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.9||||3.9|1.16|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.9||||3.9|1.16|2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.9||||3.9||2.69|1.16
7904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 2 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.9||||3.9||2.69|1.16
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|5.91||||5.91|2.61|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.91||||5.91|1.75|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|5.91||||5.91|2.78|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.91||||5.91|2.96|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.91||||5.91|2.96|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.91||||5.91|3.72|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.91||||5.91|1.75|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|5.91||||5.91|3.25|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.91||||5.91|4.08|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.91||||5.91|2.96|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.91||||5.91|2.61|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.91||||5.91|1.75|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.91||||5.91|2.61|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.91||||5.91|1.75|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.91||||5.91|1.75|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.91||||5.91|4.08|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.91||||5.91|1.75|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|Self-pay|Self-pay|5.91||||5.91|2.07|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.91||||5.91|1.75|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.91||||5.91|1.75|4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.91||||5.91||4.08|1.75
7906|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|THIOTHIXENE 5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.91||||5.91||4.08|1.75
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|AARP [1000]|AARP [100000]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|AETNA [1015]|AETNA [101529]|11.07||||11.07|4.88|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.07||||11.07|3.28|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|BCBS [1155]|BCBS UTHCT [115568]|11.07||||11.07|5.2|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.07||||11.07|5.54|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.07||||11.07|5.54|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.07||||11.07|6.97|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.07||||11.07|3.28|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|CIGNA [1260]|CIGNA GWH [126023]|11.07||||11.07|6.09|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|11.07||||11.07|7.64|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.07||||11.07|5.54|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.07||||11.07|4.88|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.07||||11.07|3.28|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.07||||11.07|4.88|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.07||||11.07|3.28|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.07||||11.07|3.28|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|11.07||||11.07|7.64|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.07||||11.07|3.28|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|Self-pay|Self-pay|11.07||||11.07|3.87|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.07||||11.07|3.28|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.07||||11.07|3.28|7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.07||||11.07||7.64|3.28
8020|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLNAFTATE 1 % TOPICAL CREAM|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.07||||11.07||7.64|3.28
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.12||||1.12|0.49|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.12||||1.12|0.33|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.12||||1.12|0.53|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.12||||1.12|0.56|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.12||||1.12|0.56|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.12||||1.12|0.71|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.12||||1.12|0.33|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.12||||1.12|0.62|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.12||||1.12|0.77|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.12||||1.12|0.56|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.12||||1.12|0.49|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.12||||1.12|0.33|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.12||||1.12|0.49|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.12||||1.12|0.33|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.12||||1.12|0.33|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.12||||1.12|0.77|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.12||||1.12|0.33|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|Self-pay|Self-pay|1.12||||1.12|0.39|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.12||||1.12|0.33|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.12||||1.12|0.33|0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.12||||1.12||0.77|0.33
8084|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.12||||1.12||0.77|0.33
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.41||||0.41|0.18|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.41||||0.41|0.12|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.41||||0.41|0.19|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.41||||0.41|0.21|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.41||||0.41|0.21|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.41||||0.41|0.26|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.41||||0.41|0.12|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.41||||0.41|0.23|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.41||||0.41|0.28|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.41||||0.41|0.21|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.41||||0.41|0.18|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.41||||0.41|0.12|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.41||||0.41|0.18|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.41||||0.41|0.12|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.41||||0.41|0.12|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.41||||0.41|0.28|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.41||||0.41|0.12|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.41||||0.41|0.14|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.41||||0.41|0.12|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.41||||0.41|0.12|0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.41||||0.41||0.28|0.12
8085|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRAZODONE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.41||||0.41||0.28|0.12
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|10.05||||10.05|4.43|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.05||||10.05|2.98|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BCBS UTHCT [115568]|10.05||||10.05|4.72|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.05||||10.05|5.03|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.05||||10.05|5.03|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.05||||10.05|6.33|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.05||||10.05|2.98|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA GWH [126023]|10.05||||10.05|5.53|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|10.05||||10.05|6.93|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.05||||10.05|5.03|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.05||||10.05|4.43|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.05||||10.05|2.98|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.05||||10.05|4.43|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.05||||10.05|2.98|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.05||||10.05|2.98|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|10.05||||10.05|6.93|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.05||||10.05|2.98|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|Self-pay|Self-pay|10.05||||10.05|3.52|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.05||||10.05|2.98|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.05||||10.05|2.98|6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.05||||10.05||6.93|2.98
8113|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.05||||10.05||6.93|2.98
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AARP [1000]|AARP [100000]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AETNA [1015]|AETNA [101529]|14||||14|6.17|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14||||14|4.15|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BCBS UTHCT [115568]|14||||14|6.58|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14||||14|7|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14||||14|7|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14||||14|8.82|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14||||14|4.15|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|CIGNA [1260]|CIGNA GWH [126023]|14||||14|7.7|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|14||||14|9.66|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14||||14|7|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14||||14|6.17|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14||||14|4.15|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14||||14|6.17|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14||||14|4.15|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|14||||14|4.15|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|14||||14|9.66|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14||||14|4.15|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|Self-pay|Self-pay|14||||14|4.9|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14||||14|4.15|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14||||14|4.15|9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14||||14||9.66|4.15
8118|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMCINOLONE ACETONIDE 0.1 % TOPICAL OINTMENT|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14||||14||9.66|4.15
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AARP [1000]|AARP [100000]|26.35||||26.35|8.84|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|26.35||||26.35||18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AETNA [1015]|AETNA [101529]|26.35||||26.35|14.21|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|26.35||||26.35|7.81|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|26.35||||26.35||18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|26.35||||26.35||18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|26.35||||26.35|12.38|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|26.35||||26.35|0|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|26.35||||26.35|13.18|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|26.35||||26.35|16.6|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|26.35||||26.35|7.81|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|26.35||||26.35||18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|26.35||||26.35|14.49|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|26.35||||26.35|18.18|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|26.35||||26.35|1.73|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|26.35||||26.35||18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|26.35||||26.35|14.21|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|26.35||||26.35|7.81|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|26.35||||26.35||18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|26.35||||26.35|14.21|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|26.35||||26.35|7.81|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|26.35||||26.35|7.81|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|26.35||||26.35|18.18|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|26.35||||26.35|7.81|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|Self-pay|Self-pay|26.35||||26.35|9.22|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|26.35||||26.35|7.81|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|26.35||||26.35|7.81|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|26.35||||26.35|8.84|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|26.35||||26.35||18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|26.35||||26.35||18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|26.35||||26.35|8.84|18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|26.35||||26.35||18.18|1.73
8120|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|26.35||||26.35||18.18|1.73
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.86||||0.86|0.38|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.86||||0.86|0.25|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.86||||0.86|0.4|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.86||||0.86|0.43|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.86||||0.86|0.43|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.86||||0.86|0.54|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.86||||0.86|0.25|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.86||||0.86|0.47|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.86||||0.86|0.59|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.86||||0.86|0.43|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.86||||0.86|0.38|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.86||||0.86|0.25|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.86||||0.86|0.38|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.86||||0.86|0.25|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.86||||0.86|0.25|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.86||||0.86|0.59|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.86||||0.86|0.25|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|Self-pay|Self-pay|0.86||||0.86|0.3|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.86||||0.86|0.25|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.86||||0.86|0.25|0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.86||||0.86||0.59|0.25
8132|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.86||||0.86||0.59|0.25
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.88||||0.88|0.39|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.88||||0.88|0.26|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.88||||0.88|0.41|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.88||||0.88|0.44|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.88||||0.88|0.44|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.88||||0.88|0.55|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.88||||0.88|0.26|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.88||||0.88|0.48|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.88||||0.88|0.61|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.88||||0.88|0.44|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.88||||0.88|0.39|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.88||||0.88|0.26|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.88||||0.88|0.39|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.88||||0.88|0.26|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.88||||0.88|0.26|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.88||||0.88|0.61|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.88||||0.88|0.26|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.88||||0.88|0.31|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.88||||0.88|0.26|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.88||||0.88|0.26|0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.88||||0.88||0.61|0.26
8134|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIAMTERENE 75 MG-HYDROCHLOROTHIAZIDE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.88||||0.88||0.61|0.26
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|6.78||||6.78|2.99|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.78||||6.78|2.01|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|6.78||||6.78|3.19|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.78||||6.78|3.39|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.78||||6.78|3.39|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.78||||6.78|4.27|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.78||||6.78|2.01|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|6.78||||6.78|3.73|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.78||||6.78|4.68|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.78||||6.78|3.39|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.78||||6.78|2.99|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.78||||6.78|2.01|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.78||||6.78|2.99|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.78||||6.78|2.01|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.78||||6.78|2.01|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.78||||6.78|4.68|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.78||||6.78|2.01|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|6.78||||6.78|2.37|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.78||||6.78|2.01|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.78||||6.78|2.01|4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.78||||6.78||4.68|2.01
81426|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIVALPROEX ER 500 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.78||||6.78||4.68|2.01
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|AARP [1000]|AARP [100000]|1085||||1085|505.6|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1085||||1085||748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|AETNA [1015]|AETNA [101529]|1085||||1085|136.68|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1085||||1085|321.7|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1085||||1085||748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1085||||1085||748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|BCBS [1155]|BCBS UTHCT [115568]|1085||||1085|509.95|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1085||||1085|0|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1085||||1085|542.5|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1085||||1085|683.55|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1085||||1085|321.7|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1085||||1085||748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|CIGNA [1260]|CIGNA GWH [126023]|1085||||1085|542.5|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1085||||1085|748.65|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1085||||1085|12.88|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1085||||1085||748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1085||||1085|136.68|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1085||||1085|321.7|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1085||||1085||748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1085||||1085|136.68|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1085||||1085|321.7|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1085||||1085|321.7|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1085||||1085|748.65|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1085||||1085|321.7|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|Self-pay|Self-pay|1085||||1085|379.75|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1085||||1085|321.7|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1085||||1085|321.7|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1085||||1085|505.6|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1085||||1085||748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1085||||1085||748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1085||||1085|505.6|748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1085||||1085||748.65|12.88
81434|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ZOLEDRONIC ACID 5 MG/100 ML IN MANNITOL 5 %-WATER INTRAVENOUS PIGGYBCK|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1085||||1085||748.65|12.88
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|AARP [1000]|AARP [100000]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|AETNA [1015]|AETNA [101529]|0.7||||0.7|0.31|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.7||||0.7|0.21|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|BCBS [1155]|BCBS UTHCT [115568]|0.7||||0.7|0.33|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.7||||0.7|0.35|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.7||||0.7|0.35|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.7||||0.7|0.44|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.7||||0.7|0.21|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|CIGNA [1260]|CIGNA GWH [126023]|0.7||||0.7|0.39|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.7||||0.7|0.48|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.7||||0.7|0.35|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.7||||0.7|0.31|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.7||||0.7|0.21|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.7||||0.7|0.31|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.7||||0.7|0.21|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.7||||0.7|0.21|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.7||||0.7|0.48|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.7||||0.7|0.21|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|Self-pay|Self-pay|0.7||||0.7|0.24|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.7||||0.7|0.21|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.7||||0.7|0.21|0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.7||||0.7||0.48|0.21
8165|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 0.4 MG/ML ORAL ELIXIR|2.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.7||||0.7||0.48|0.21
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.47||||0.47|0.21|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.47||||0.47|0.14|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.47||||0.47|0.22|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.47||||0.47|0.24|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.47||||0.47|0.24|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.47||||0.47|0.3|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.47||||0.47|0.14|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.47||||0.47|0.26|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.47||||0.47|0.32|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.47||||0.47|0.24|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.47||||0.47|0.21|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.47||||0.47|0.14|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.47||||0.47|0.21|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.47||||0.47|0.14|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.47||||0.47|0.14|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.47||||0.47|0.32|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.47||||0.47|0.14|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|Self-pay|Self-pay|0.47||||0.47|0.16|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.47||||0.47|0.14|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.47||||0.47|0.14|0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.47||||0.47||0.32|0.14
8166|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.47||||0.47||0.32|0.14
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.95||||0.95|0.42|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.95||||0.95|0.28|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.95||||0.95|0.45|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.95||||0.95|0.48|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.95||||0.95|0.48|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.95||||0.95|0.6|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.95||||0.95|0.28|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.95||||0.95|0.52|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.95||||0.95|0.66|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.95||||0.95|0.48|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.95||||0.95|0.42|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.95||||0.95|0.28|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.95||||0.95|0.42|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.95||||0.95|0.28|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.95||||0.95|0.28|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.95||||0.95|0.66|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.95||||0.95|0.28|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.95||||0.95|0.33|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.95||||0.95|0.28|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.95||||0.95|0.28|0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.95||||0.95||0.66|0.28
8167|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TRIHEXYPHENIDYL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.95||||0.95||0.66|0.28
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|AARP [1000]|AARP [100000]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|AETNA [1015]|AETNA [101529]|65.99||||65.99|29.1|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|65.99||||65.99|19.57|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|BCBS [1155]|BCBS UTHCT [115568]|65.99||||65.99|31.02|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|65.99||||65.99|33|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|65.99||||65.99|33|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|65.99||||65.99|41.57|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|65.99||||65.99|19.57|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|CIGNA [1260]|CIGNA GWH [126023]|65.99||||65.99|36.29|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|65.99||||65.99|45.53|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|65.99||||65.99|33|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|65.99||||65.99|29.1|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|65.99||||65.99|19.57|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|65.99||||65.99|29.1|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|65.99||||65.99|19.57|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|65.99||||65.99|19.57|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|65.99||||65.99|45.53|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|65.99||||65.99|19.57|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|Self-pay|Self-pay|65.99||||65.99|23.1|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|65.99||||65.99|19.57|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|65.99||||65.99|19.57|45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|65.99||||65.99||45.53|19.57
82033|ERX|0250 - PHARMACY-GENERAL|GLYCERIN 99.5 % TOPICAL SOLUTION|473 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|65.99||||65.99||45.53|19.57
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|13.64||||13.64|6.02|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.64||||13.64|4.04|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|13.64||||13.64|6.41|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.64||||13.64|6.82|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.64||||13.64|6.82|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.64||||13.64|8.59|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.64||||13.64|4.04|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|13.64||||13.64|7.5|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.64||||13.64|9.41|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.64||||13.64|6.82|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.64||||13.64|6.02|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.64||||13.64|4.04|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.64||||13.64|6.02|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.64||||13.64|4.04|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.64||||13.64|4.04|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.64||||13.64|9.41|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.64||||13.64|4.04|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|13.64||||13.64|4.77|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.64||||13.64|4.04|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.64||||13.64|4.04|9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.64||||13.64||9.41|4.04
82085|ERX|0250 - PHARMACY-GENERAL|ESMOLOL 100 MG/10 ML (10 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.64||||13.64||9.41|4.04
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AARP [1000]|AARP [100000]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AETNA [1015]|AETNA [101529]|1.03||||1.03|0.45|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.03||||1.03|0.31|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|1.03||||1.03|0.48|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.03||||1.03|0.52|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.03||||1.03|0.52|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.03||||1.03|0.65|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.03||||1.03|0.31|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|1.03||||1.03|0.57|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.03||||1.03|0.71|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.03||||1.03|0.52|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.03||||1.03|0.45|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.03||||1.03|0.31|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.03||||1.03|0.45|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.03||||1.03|0.31|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.03||||1.03|0.31|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.03||||1.03|0.71|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.03||||1.03|0.31|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|Self-pay|Self-pay|1.03||||1.03|0.36|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.03||||1.03|0.31|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.03||||1.03|0.31|0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.03||||1.03||0.71|0.31
82134|ERX|0250 - PHARMACY-GENERAL|SODIUM CHLORIDE 7 % FOR NEBULIZATION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.03||||1.03||0.71|0.31
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AARP [1000]|AARP [100000]|39.84||||39.84|32.55|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|39.84||||39.84||32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|39.84||||39.84|19.08|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|39.84||||39.84|11.81|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|39.84||||39.84||32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|39.84||||39.84||32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|39.84||||39.84|18.72|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|39.84||||39.84|0|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|39.84||||39.84|19.92|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|39.84||||39.84|25.1|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|39.84||||39.84|11.81|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|39.84||||39.84||32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|39.84||||39.84|21.91|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|39.84||||39.84|27.49|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|39.84||||39.84|2.1|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|39.84||||39.84||32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|39.84||||39.84|19.08|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|39.84||||39.84|11.81|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|39.84||||39.84||32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|39.84||||39.84|19.08|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|39.84||||39.84|11.81|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|39.84||||39.84|11.81|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|39.84||||39.84|27.49|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|39.84||||39.84|11.81|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|Self-pay|Self-pay|39.84||||39.84|13.94|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|39.84||||39.84|11.81|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|39.84||||39.84|11.81|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|39.84||||39.84|32.55|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|39.84||||39.84||32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|39.84||||39.84||32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|39.84||||39.84|32.55|32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|39.84||||39.84||32.55|2.1
82180|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 2.5 GRAM/50 ML INTRAVENOUS SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|39.84||||39.84||32.55|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|9.3||||9.3|6.51|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.3||||9.3||6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|9.3||||9.3|3.82|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.3||||9.3|2.76|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.3||||9.3||6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.3||||9.3||6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|9.3||||9.3|4.37|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.3||||9.3|0|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.3||||9.3|4.65|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.3||||9.3|5.86|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.3||||9.3|2.76|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.3||||9.3||6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|9.3||||9.3|5.12|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.3||||9.3|6.42|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.3||||9.3|2.1|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.3||||9.3||6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.3||||9.3|3.82|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.3||||9.3|2.76|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.3||||9.3||6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.3||||9.3|3.82|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.3||||9.3|2.76|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.3||||9.3|2.76|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.3||||9.3|6.42|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.3||||9.3|2.76|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|9.3||||9.3|3.25|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.3||||9.3|2.76|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.3||||9.3|2.76|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.3||||9.3|6.51|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.3||||9.3||6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.3||||9.3||6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.3||||9.3|6.51|6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.3||||9.3||6.51|2.1
82200|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 500 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.3||||9.3||6.51|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|18.6||||18.6|13.02|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.6||||18.6||13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|18.6||||18.6|7.63|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.6||||18.6|5.51|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.6||||18.6||13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.6||||18.6||13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|18.6||||18.6|8.74|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.6||||18.6|0|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.6||||18.6|9.3|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.6||||18.6|11.72|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.6||||18.6|5.51|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.6||||18.6||13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|18.6||||18.6|10.23|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.6||||18.6|12.83|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.6||||18.6|2.1|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.6||||18.6||13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.6||||18.6|7.63|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.6||||18.6|5.51|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.6||||18.6||13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.6||||18.6|7.63|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.6||||18.6|5.51|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.6||||18.6|5.51|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.6||||18.6|12.83|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.6||||18.6|5.51|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|18.6||||18.6|6.51|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.6||||18.6|5.51|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.6||||18.6|5.51|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.6||||18.6|13.02|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.6||||18.6||13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.6||||18.6||13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.6||||18.6|13.02|13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.6||||18.6||13.02|2.1
82204|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.6||||18.6||13.02|2.1
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|AARP [1000]|AARP [100000]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|AETNA [1015]|AETNA [101529]|5513.17||||5513.17|3204.72|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5513.17||||5513.17|1634.65|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|BCBS [1155]|BCBS UTHCT [115568]|5513.17||||5513.17|2591.19|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5513.17||||5513.17|0|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5513.17||||5513.17|2756.59|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5513.17||||5513.17|3473.3|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5513.17||||5513.17|1634.65|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|CIGNA [1260]|CIGNA GWH [126023]|5513.17||||5513.17|2756.59|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|5513.17||||5513.17|3804.09|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5513.17||||5513.17|53.58|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5513.17||||5513.17|3204.72|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5513.17||||5513.17|1634.65|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5513.17||||5513.17|3204.72|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5513.17||||5513.17|1634.65|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|5513.17||||5513.17|1634.65|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|5513.17||||5513.17|3804.09|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5513.17||||5513.17|1634.65|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|Self-pay|Self-pay|5513.17||||5513.17|1929.61|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5513.17||||5513.17|1634.65|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5513.17||||5513.17|1634.65|3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5513.17||||5513.17||3804.09|53.58
82228|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|TEMSIROLIMUS 30 MG/3 ML (10 MG/ML) (FIRST DILUTION) INTRAVENOUS SOLN|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5513.17||||5513.17||3804.09|53.58
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|8.73||||8.73|3.85|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.73||||8.73|2.59|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|8.73||||8.73|4.1|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.73||||8.73|4.37|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.73||||8.73|4.37|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.73||||8.73|5.5|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.73||||8.73|2.59|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|8.73||||8.73|4.8|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.73||||8.73|6.02|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.73||||8.73|4.37|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.73||||8.73|3.85|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.73||||8.73|2.59|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.73||||8.73|3.85|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.73||||8.73|2.59|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.73||||8.73|2.59|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.73||||8.73|6.02|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.73||||8.73|2.59|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|8.73||||8.73|3.06|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.73||||8.73|2.59|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.73||||8.73|2.59|6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.73||||8.73||6.02|2.59
82301|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 150 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.73||||8.73||6.02|2.59
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|AARP [1000]|AARP [100000]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|AETNA [1015]|AETNA [101529]|94.86||||94.86|41.83|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|94.86||||94.86|28.13|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|94.86||||94.86|44.58|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|94.86||||94.86|47.43|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|94.86||||94.86|47.43|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|94.86||||94.86|59.76|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|94.86||||94.86|28.13|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|94.86||||94.86|52.17|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|94.86||||94.86|65.45|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|94.86||||94.86|47.43|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|94.86||||94.86|41.83|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|94.86||||94.86|28.13|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|94.86||||94.86|41.83|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|94.86||||94.86|28.13|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|94.86||||94.86|28.13|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|94.86||||94.86|65.45|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|94.86||||94.86|28.13|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|Self-pay|Self-pay|94.86||||94.86|33.2|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|94.86||||94.86|28.13|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|94.86||||94.86|28.13|65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|94.86||||94.86||65.45|28.13
8250|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TROPICAMIDE 1 % EYE DROPS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|94.86||||94.86||65.45|28.13
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AARP [1000]|AARP [100000]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AETNA [1015]|AETNA [101529]|27.82||||27.82|12.27|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.82||||27.82|8.25|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS [1155]|BCBS UTHCT [115568]|27.82||||27.82|13.08|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.82||||27.82|13.91|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.82||||27.82|13.91|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.82||||27.82|17.53|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.82||||27.82|8.25|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|CIGNA [1260]|CIGNA GWH [126023]|27.82||||27.82|15.3|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.82||||27.82|19.2|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.82||||27.82|13.91|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.82||||27.82|12.27|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.82||||27.82|8.25|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.82||||27.82|12.27|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.82||||27.82|8.25|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.82||||27.82|8.25|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.82||||27.82|19.2|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.82||||27.82|8.25|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|Self-pay|Self-pay|27.82||||27.82|9.74|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.82||||27.82|8.25|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.82||||27.82|8.25|19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.82||||27.82||19.2|8.25
8259|ERX|0250 - PHARMACY-GENERAL|TUBERCULIN PPD 5 TUB. UNIT/0.1 ML INTRADERMAL INJECTION SOLUTION|0.1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.82||||27.82||19.2|8.25
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AARP [1000]|AARP [100000]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AETNA [1015]|AETNA [101529]|49.29||||49.29|13.3|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|49.29||||49.29|14.61|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS [1155]|BCBS UTHCT [115568]|49.29||||49.29|23.17|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|49.29||||49.29|0|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|49.29||||49.29|24.65|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|49.29||||49.29|31.05|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|49.29||||49.29|14.61|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|CIGNA [1260]|CIGNA GWH [126023]|49.29||||49.29|27.11|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|49.29||||49.29|34.01|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|49.29||||49.29|3.26|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|49.29||||49.29|13.3|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|49.29||||49.29|14.61|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|49.29||||49.29|13.3|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|49.29||||49.29|14.61|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|49.29||||49.29|14.61|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|49.29||||49.29|34.01|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|49.29||||49.29|14.61|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|Self-pay|Self-pay|49.29||||49.29|17.25|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|49.29||||49.29|14.61|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|49.29||||49.29|14.61|34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|49.29||||49.29||34.01|3.26
8442|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION|1,000 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|49.29||||49.29||34.01|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AARP [1000]|AARP [100000]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AETNA [1015]|AETNA [101529]|24.93||||24.93|6.65|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|24.93||||24.93|7.39|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|24.93||||24.93|11.72|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|24.93||||24.93|0|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|24.93||||24.93|12.47|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|24.93||||24.93|15.71|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|24.93||||24.93|7.39|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|24.93||||24.93|13.71|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|24.93||||24.93|17.2|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|24.93||||24.93|3.26|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|24.93||||24.93|6.65|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|24.93||||24.93|7.39|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|24.93||||24.93|6.65|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|24.93||||24.93|7.39|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|24.93||||24.93|7.39|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|24.93||||24.93|17.2|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|24.93||||24.93|7.39|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|Self-pay|Self-pay|24.93||||24.93|8.73|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|24.93||||24.93|7.39|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|24.93||||24.93|7.39|17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|24.93||||24.93||17.2|3.26
8443|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 500 MG INTRAVENOUS SOLUTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|24.93||||24.93||17.2|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AARP [1000]|AARP [100000]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AETNA [1015]|AETNA [101529]|275.69||||275.69|66.48|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|275.69||||275.69|81.74|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BCBS UTHCT [115568]|275.69||||275.69|129.57|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|275.69||||275.69|0|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|275.69||||275.69|137.85|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|275.69||||275.69|173.68|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|275.69||||275.69|81.74|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|CIGNA [1260]|CIGNA GWH [126023]|275.69||||275.69|151.63|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|275.69||||275.69|190.23|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|275.69||||275.69|3.26|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|275.69||||275.69|66.48|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|275.69||||275.69|81.74|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|275.69||||275.69|66.48|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|275.69||||275.69|81.74|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|275.69||||275.69|81.74|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|275.69||||275.69|190.23|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|275.69||||275.69|81.74|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|Self-pay|Self-pay|275.69||||275.69|96.49|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|275.69||||275.69|81.74|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|275.69||||275.69|81.74|190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|275.69||||275.69||190.23|3.26
8444|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 5 GRAM INTRAVENOUS SOLUTION|5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|275.69||||275.69||190.23|3.26
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|31||||31|13.67|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|9.19|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|15.5|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|9.19|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|31||||31|17.05|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|15.5|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|13.67|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|9.19|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|13.67|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|9.19|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|9.19|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|9.19|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|31||||31|10.85|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|9.19|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|9.19|21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31||21.39|9.19
8527|ERX|0250 - PHARMACY-GENERAL|VERAPAMIL 2.5 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31||21.39|9.19
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.49||||0.49|0.22|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.49||||0.49|0.15|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.49||||0.49|0.23|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.49||||0.49|0.25|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.49||||0.49|0.25|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.49||||0.49|0.31|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.49||||0.49|0.15|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.49||||0.49|0.27|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.49||||0.49|0.34|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.49||||0.49|0.25|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.49||||0.49|0.22|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.49||||0.49|0.15|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.49||||0.49|0.22|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.49||||0.49|0.15|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.49||||0.49|0.15|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.49||||0.49|0.34|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.49||||0.49|0.15|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|Self-pay|Self-pay|0.49||||0.49|0.17|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.49||||0.49|0.15|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.49||||0.49|0.15|0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.49||||0.49||0.34|0.15
8529|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|VERAPAMIL 40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.49||||0.49||0.34|0.15
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AARP [1000]|AARP [100000]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AETNA [1015]|AETNA [101529]|71.06||||71.06|31.34|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.06||||71.06|21.07|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BCBS UTHCT [115568]|71.06||||71.06|33.4|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.06||||71.06|35.53|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.06||||71.06|35.53|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.06||||71.06|44.77|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.06||||71.06|21.07|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|CIGNA [1260]|CIGNA GWH [126023]|71.06||||71.06|39.08|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|71.06||||71.06|49.03|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71.06||||71.06|35.53|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.06||||71.06|31.34|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.06||||71.06|21.07|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.06||||71.06|31.34|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.06||||71.06|21.07|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|71.06||||71.06|21.07|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|71.06||||71.06|49.03|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.06||||71.06|21.07|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|Self-pay|Self-pay|71.06||||71.06|24.87|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71.06||||71.06|21.07|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.06||||71.06|21.07|49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.06||||71.06||49.03|21.07
856|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACITRACIN-POLYMYXIN B 500 UNIT-10,000 UNIT/GRAM EYE OINTMENT|3.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.06||||71.06||49.03|21.07
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|146.2||||146.2|46.5|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|146.2||||146.2||100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|146.2||||146.2|95.28|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|146.2||||146.2|43.35|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|146.2||||146.2||100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|146.2||||146.2||100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|146.2||||146.2|68.71|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|146.2||||146.2|0|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|146.2||||146.2|73.1|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|146.2||||146.2|92.11|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|146.2||||146.2|43.35|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|146.2||||146.2||100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|146.2||||146.2|80.41|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|146.2||||146.2|100.88|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|146.2||||146.2|4.6|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|146.2||||146.2||100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|146.2||||146.2|95.28|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|146.2||||146.2|43.35|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|146.2||||146.2||100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|146.2||||146.2|95.28|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|146.2||||146.2|43.35|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|146.2||||146.2|43.35|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|146.2||||146.2|100.88|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|146.2||||146.2|43.35|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|146.2||||146.2|51.17|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|146.2||||146.2|43.35|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|146.2||||146.2|43.35|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|146.2||||146.2|46.5|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|146.2||||146.2||100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|146.2||||146.2||100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|146.2||||146.2|46.5|100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|146.2||||146.2||100.88|4.6
8594|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINBLASTINE 1 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|146.2||||146.2||100.88|4.6
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|AARP [1000]|AARP [100000]|35.84||||35.84|11.9|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.84||||35.84||25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|35.84||||35.84|25.3|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.84||||35.84|10.63|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.84||||35.84||25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.84||||35.84||25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|35.84||||35.84|16.84|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.84||||35.84|0|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.84||||35.84|17.92|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.84||||35.84|22.58|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.84||||35.84|10.63|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.84||||35.84||25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|35.84||||35.84|19.71|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|35.84||||35.84|24.73|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35.84||||35.84|6.3|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.84||||35.84||25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.84||||35.84|25.3|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.84||||35.84|10.63|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.84||||35.84||25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.84||||35.84|25.3|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.84||||35.84|10.63|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|35.84||||35.84|10.63|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|35.84||||35.84|24.73|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.84||||35.84|10.63|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|Self-pay|Self-pay|35.84||||35.84|12.54|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35.84||||35.84|10.63|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.84||||35.84|10.63|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.84||||35.84|11.9|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35.84||||35.84||25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35.84||||35.84||25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.84||||35.84|11.9|25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.84||||35.84||25.3|6.3
8597|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VINCRISTINE 1 MG/ML INTRAVENOUS SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.84||||35.84||25.3|6.3
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.31||||1.31|0.58|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.31||||1.31|0.39|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.31||||1.31|0.62|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.31||||1.31|0.66|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.31||||1.31|0.66|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.31||||1.31|0.83|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.31||||1.31|0.39|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.31||||1.31|0.72|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.31||||1.31|0.9|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.31||||1.31|0.66|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.31||||1.31|0.58|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.31||||1.31|0.39|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.31||||1.31|0.58|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.31||||1.31|0.39|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.31||||1.31|0.39|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.31||||1.31|0.9|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.31||||1.31|0.39|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.31||||1.31|0.46|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.31||||1.31|0.39|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.31||||1.31|0.39|0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.31||||1.31||0.9|0.39
860|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BACLOFEN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.31||||1.31||0.9|0.39
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.62||||1.62|0.71|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.62||||1.62|0.48|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.62||||1.62|0.76|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.62||||1.62|0.81|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.62||||1.62|0.81|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.62||||1.62|1.02|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.62||||1.62|0.48|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.62||||1.62|0.89|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.62||||1.62|1.12|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.62||||1.62|0.81|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.62||||1.62|0.71|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.62||||1.62|0.48|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.62||||1.62|0.71|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.62||||1.62|0.48|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.62||||1.62|0.48|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.62||||1.62|1.12|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.62||||1.62|0.48|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.62||||1.62|0.57|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.62||||1.62|0.48|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.62||||1.62|0.48|1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.62||||1.62||1.12|0.48
8748|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.62||||1.62||1.12|0.48
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|AARP [1000]|AARP [100000]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|AETNA [1015]|AETNA [101529]|1.42||||1.42|0.63|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.42||||1.42|0.42|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.42||||1.42|0.67|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.42||||1.42|0.71|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.42||||1.42|0.71|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.42||||1.42|0.89|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.42||||1.42|0.42|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.42||||1.42|0.78|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.42||||1.42|0.98|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.42||||1.42|0.71|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.42||||1.42|0.63|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.42||||1.42|0.42|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.42||||1.42|0.63|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.42||||1.42|0.42|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.42||||1.42|0.42|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.42||||1.42|0.98|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.42||||1.42|0.42|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|Self-pay|Self-pay|1.42||||1.42|0.5|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.42||||1.42|0.42|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.42||||1.42|0.42|0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.42||||1.42||0.98|0.42
8749|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2 MG TABLET|2 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.42||||1.42||0.98|0.42
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.21||||1.21|0.53|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.21||||1.21|0.36|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.21||||1.21|0.57|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.21||||1.21|0.61|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.21||||1.21|0.61|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.21||||1.21|0.76|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.21||||1.21|0.36|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.21||||1.21|0.67|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.21||||1.21|0.83|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.21||||1.21|0.61|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.21||||1.21|0.53|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.21||||1.21|0.36|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.21||||1.21|0.53|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.21||||1.21|0.36|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.21||||1.21|0.36|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.21||||1.21|0.83|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.21||||1.21|0.36|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.21||||1.21|0.42|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.21||||1.21|0.36|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.21||||1.21|0.36|0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.21||||1.21||0.83|0.36
8750|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.21||||1.21||0.83|0.36
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.03||||1.03|0.45|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.03||||1.03|0.31|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.03||||1.03|0.48|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.03||||1.03|0.52|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.03||||1.03|0.52|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.03||||1.03|0.65|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.03||||1.03|0.31|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.03||||1.03|0.57|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.03||||1.03|0.71|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.03||||1.03|0.52|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.03||||1.03|0.45|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.03||||1.03|0.31|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.03||||1.03|0.45|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.03||||1.03|0.31|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.03||||1.03|0.31|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.03||||1.03|0.71|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.03||||1.03|0.31|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|Self-pay|Self-pay|1.03||||1.03|0.36|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.03||||1.03|0.31|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.03||||1.03|0.31|0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.03||||1.03||0.71|0.31
8751|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.03||||1.03||0.71|0.31
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.09||||1.09|0.48|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.09||||1.09|0.32|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.09||||1.09|0.51|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.09||||1.09|0.55|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.09||||1.09|0.55|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.09||||1.09|0.69|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.09||||1.09|0.32|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.09||||1.09|0.6|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.09||||1.09|0.75|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.09||||1.09|0.55|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.09||||1.09|0.48|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.09||||1.09|0.32|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.09||||1.09|0.48|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.09||||1.09|0.32|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.09||||1.09|0.32|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.09||||1.09|0.75|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.09||||1.09|0.32|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.09||||1.09|0.38|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.09||||1.09|0.32|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.09||||1.09|0.32|0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.09||||1.09||0.75|0.32
8752|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|WARFARIN 7.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.09||||1.09||0.75|0.32
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|AARP [1000]|AARP [100000]|14182.5||||14182.5|7091.25|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14182.5||||14182.5|4098.86|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|AETNA [1015]|AETNA [101529]|14182.5||||14182.5|10140.48|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14182.5||||14182.5|4205.11|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14182.5||||14182.5|4058.28|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14182.5||||14182.5|4058.28|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|BCBS [1155]|BCBS UTHCT [115568]|14182.5||||14182.5|6665.78|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14182.5||||14182.5|0|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14182.5||||14182.5|7091.25|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14182.5||||14182.5|8934.98|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14182.5||||14182.5|4205.11|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14182.5||||14182.5|4058.28|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|CIGNA [1260]|CIGNA GWH [126023]|14182.5||||14182.5|7091.25|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14182.5||||14182.5|9785.93|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14182.5||||14182.5|85.58|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14182.5||||14182.5|4058.28|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14182.5||||14182.5|10140.48|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14182.5||||14182.5|4205.11|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14182.5||||14182.5|4058.28|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14182.5||||14182.5|10140.48|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14182.5||||14182.5|4205.11|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14182.5||||14182.5|4205.11|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14182.5||||14182.5|9785.93|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14182.5||||14182.5|4205.11|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|Self-pay|Self-pay|14182.5||||14182.5|4963.87|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14182.5||||14182.5|4205.11|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14182.5||||14182.5|4205.11|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14182.5||||14182.5|7091.25|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14182.5||||14182.5|4058.28|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14182.5||||14182.5|4058.28|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14182.5||||14182.5|7091.25|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14182.5||||14182.5|4058.28|10140.48|85.58
87861|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|LANREOTIDE 120 MG/0.5 ML SUBCUTANEOUS SYRINGE|0.25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14182.5||||14182.5|8116.56|10140.48|85.58
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|AARP [1000]|AARP [100000]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|AETNA [1015]|AETNA [101529]|792.83||||792.83|349.64|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|792.83||||792.83|235.07|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|BCBS [1155]|BCBS UTHCT [115568]|792.83||||792.83|372.63|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|792.83||||792.83|396.42|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|792.83||||792.83|396.42|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|792.83||||792.83|499.48|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|792.83||||792.83|235.07|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|CIGNA [1260]|CIGNA GWH [126023]|792.83||||792.83|436.06|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|792.83||||792.83|547.05|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|792.83||||792.83|396.42|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|792.83||||792.83|349.64|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|792.83||||792.83|235.07|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|792.83||||792.83|349.64|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|792.83||||792.83|235.07|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|792.83||||792.83|235.07|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|792.83||||792.83|547.05|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|792.83||||792.83|235.07|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|Self-pay|Self-pay|792.83||||792.83|277.49|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|792.83||||792.83|235.07|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|792.83||||792.83|235.07|547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|792.83||||792.83||547.05|235.07
87865|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 2.5 MG RECTAL KIT|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|792.83||||792.83||547.05|235.07
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|AARP [1000]|AARP [100000]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|AETNA [1015]|AETNA [101529]|940.48||||940.48|414.75|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|940.48||||940.48|278.85|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|BCBS [1155]|BCBS UTHCT [115568]|940.48||||940.48|442.03|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|940.48||||940.48|470.24|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|940.48||||940.48|470.24|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|940.48||||940.48|592.5|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|940.48||||940.48|278.85|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|CIGNA [1260]|CIGNA GWH [126023]|940.48||||940.48|517.26|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|940.48||||940.48|648.93|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|940.48||||940.48|470.24|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|940.48||||940.48|414.75|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|940.48||||940.48|278.85|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|940.48||||940.48|414.75|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|940.48||||940.48|278.85|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|940.48||||940.48|278.85|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|940.48||||940.48|648.93|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|940.48||||940.48|278.85|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|Self-pay|Self-pay|940.48||||940.48|329.17|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|940.48||||940.48|278.85|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|940.48||||940.48|278.85|648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|940.48||||940.48||648.93|278.85
87867|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DIAZEPAM 5 MG-7.5 MG-10 MG RECTAL KIT|10 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|940.48||||940.48||648.93|278.85
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AARP [1000]|AARP [100000]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.45||||1.45|0.64|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.45||||1.45|0.43|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.45||||1.45|0.68|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.45||||1.45|0.73|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.45||||1.45|0.73|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.45||||1.45|0.91|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.45||||1.45|0.43|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.45||||1.45|0.8|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.45||||1.45|1|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.45||||1.45|0.73|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.45||||1.45|0.64|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.45||||1.45|0.43|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.45||||1.45|0.64|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.45||||1.45|0.43|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.45||||1.45|0.43|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.45||||1.45|1|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.45||||1.45|0.43|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|Self-pay|Self-pay|1.45||||1.45|0.51|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.45||||1.45|0.43|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.45||||1.45|0.43|1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.45||||1.45||1|0.43
87912|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|POTASSIUM BICARBONATE-CITRIC ACID 20 MEQ EFFERVESCENT TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.45||||1.45||1|0.43
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|113.9||||113.9|50.75|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|113.9||||113.9||78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|113.9||||113.9|63|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|113.9||||113.9|33.77|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|113.9||||113.9||78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|113.9||||113.9||78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|113.9||||113.9|53.53|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|113.9||||113.9|0|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|113.9||||113.9|56.95|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|113.9||||113.9|71.76|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|113.9||||113.9|33.77|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|113.9||||113.9||78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|113.9||||113.9|62.65|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|113.9||||113.9|78.59|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|113.9||||113.9|32.71|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|113.9||||113.9||78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|113.9||||113.9|63|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|113.9||||113.9|33.77|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|113.9||||113.9||78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|113.9||||113.9|63|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|113.9||||113.9|33.77|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|113.9||||113.9|33.77|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|113.9||||113.9|78.59|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|113.9||||113.9|33.77|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|113.9||||113.9|39.86|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|113.9||||113.9|33.77|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|113.9||||113.9|33.77|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|113.9||||113.9|50.75|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|113.9||||113.9||78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|113.9||||113.9||78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|113.9||||113.9|50.75|78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|113.9||||113.9||78.59|32.71
87925|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 1 GRAM/20 ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|113.9||||113.9||78.59|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|AARP [1000]|AARP [100000]|333.32||||333.32|152.25|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|333.32||||333.32||229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|AETNA [1015]|AETNA [101529]|333.32||||333.32|189|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|333.32||||333.32|98.83|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|333.32||||333.32||229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|333.32||||333.32||229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BCBS UTHCT [115568]|333.32||||333.32|156.66|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|333.32||||333.32|0|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|333.32||||333.32|166.66|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|333.32||||333.32|209.99|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|333.32||||333.32|98.83|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|333.32||||333.32||229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|CIGNA [1260]|CIGNA GWH [126023]|333.32||||333.32|183.33|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|333.32||||333.32|229.99|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|333.32||||333.32|32.71|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|333.32||||333.32||229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|333.32||||333.32|189|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|333.32||||333.32|98.83|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|333.32||||333.32||229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|333.32||||333.32|189|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|333.32||||333.32|98.83|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|333.32||||333.32|98.83|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|333.32||||333.32|229.99|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|333.32||||333.32|98.83|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|Self-pay|Self-pay|333.32||||333.32|116.66|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|333.32||||333.32|98.83|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|333.32||||333.32|98.83|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|333.32||||333.32|152.25|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|333.32||||333.32||229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|333.32||||333.32||229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|333.32||||333.32|152.25|229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|333.32||||333.32||229.99|32.71
87926|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IFOSFAMIDE 3 GRAM/60 ML INTRAVENOUS SOLUTION|60 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|333.32||||333.32||229.99|32.71
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|AARP [1000]|AARP [100000]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|AETNA [1015]|AETNA [101529]|143.3||||143.3|91.8|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|143.3||||143.3|42.49|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BCBS UTHCT [115568]|143.3||||143.3|67.35|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|143.3||||143.3|0|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|143.3||||143.3|71.65|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|143.3||||143.3|90.28|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|143.3||||143.3|42.49|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|CIGNA [1260]|CIGNA GWH [126023]|143.3||||143.3|78.82|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|143.3||||143.3|98.88|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|143.3||||143.3|1.89|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|143.3||||143.3|91.8|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|143.3||||143.3|42.49|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|143.3||||143.3|91.8|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|143.3||||143.3|42.49|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|143.3||||143.3|42.49|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|143.3||||143.3|98.88|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|143.3||||143.3|42.49|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|Self-pay|Self-pay|143.3||||143.3|50.15|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|143.3||||143.3|42.49|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|143.3||||143.3|42.49|98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|143.3||||143.3||98.88|1.89
88008|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION|25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|143.3||||143.3||98.88|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|1226.36||||1226.36|367.2|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1226.36||||1226.36|363.62|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|1226.36||||1226.36|576.39|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1226.36||||1226.36|0|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1226.36||||1226.36|613.18|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1226.36||||1226.36|772.61|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1226.36||||1226.36|363.62|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|1226.36||||1226.36|613.18|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1226.36||||1226.36|846.19|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1226.36||||1226.36|1.89|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1226.36||||1226.36|367.2|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1226.36||||1226.36|363.62|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1226.36||||1226.36|367.2|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1226.36||||1226.36|363.62|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1226.36||||1226.36|363.62|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1226.36||||1226.36|846.19|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1226.36||||1226.36|363.62|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|1226.36||||1226.36|429.23|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1226.36||||1226.36|363.62|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1226.36||||1226.36|363.62|846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1226.36||||1226.36||846.19|1.89
88009|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPIRUBICIN 200 MG/100 ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1226.36||||1226.36||846.19|1.89
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|69.75||||69.75|30.76|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69.75||||69.75|20.68|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|69.75||||69.75|32.78|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69.75||||69.75|34.88|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69.75||||69.75|34.88|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69.75||||69.75|43.94|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69.75||||69.75|20.68|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|69.75||||69.75|38.36|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|69.75||||69.75|48.13|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|69.75||||69.75|34.88|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69.75||||69.75|30.76|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69.75||||69.75|20.68|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69.75||||69.75|30.76|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69.75||||69.75|20.68|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|69.75||||69.75|20.68|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|69.75||||69.75|48.13|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69.75||||69.75|20.68|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|69.75||||69.75|24.41|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|69.75||||69.75|20.68|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69.75||||69.75|20.68|48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69.75||||69.75||48.13|20.68
88010|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 500 MG PE/10 ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69.75||||69.75||48.13|20.68
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|14.88||||14.88|6.56|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.88||||14.88|4.41|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|14.88||||14.88|6.99|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.88||||14.88|7.44|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.88||||14.88|7.44|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.88||||14.88|9.37|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.88||||14.88|4.41|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|14.88||||14.88|8.18|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.88||||14.88|10.27|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.88||||14.88|7.44|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.88||||14.88|6.56|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.88||||14.88|4.41|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.88||||14.88|6.56|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.88||||14.88|4.41|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.88||||14.88|4.41|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.88||||14.88|10.27|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.88||||14.88|4.41|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|14.88||||14.88|5.21|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.88||||14.88|4.41|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.88||||14.88|4.41|10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.88||||14.88||10.27|4.41
88011|ERX|0250 - PHARMACY-GENERAL|FOSPHENYTOIN 100 MG PE/2 ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.88||||14.88||10.27|4.41
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|AARP [1000]|AARP [100000]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|AETNA [1015]|AETNA [101529]|57.63||||57.63|27.94|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|57.63||||57.63|17.09|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|57.63||||57.63|27.09|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|57.63||||57.63|0|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|57.63||||57.63|28.82|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|57.63||||57.63|36.31|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|57.63||||57.63|17.09|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|57.63||||57.63|31.7|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|57.63||||57.63|39.76|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|57.63||||57.63|14.58|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|57.63||||57.63|27.94|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|57.63||||57.63|17.09|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|57.63||||57.63|27.94|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|57.63||||57.63|17.09|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|57.63||||57.63|17.09|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|57.63||||57.63|39.76|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|57.63||||57.63|17.09|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|Self-pay|Self-pay|57.63||||57.63|20.17|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|57.63||||57.63|17.09|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|57.63||||57.63|17.09|39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|57.63||||57.63||39.76|14.58
88225|ERX|0250 - PHARMACY-GENERAL|FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|57.63||||57.63||39.76|14.58
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|635.19||||635.19|349.92|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|635.19||||635.19|188.33|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|635.19||||635.19|298.54|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|635.19||||635.19|0|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|635.19||||635.19|317.6|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|635.19||||635.19|400.17|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|635.19||||635.19|188.33|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|635.19||||635.19|317.6|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|635.19||||635.19|438.28|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|635.19||||635.19|47.18|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|635.19||||635.19|349.92|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|635.19||||635.19|188.33|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|635.19||||635.19|349.92|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|635.19||||635.19|188.33|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|635.19||||635.19|188.33|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|635.19||||635.19|438.28|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|635.19||||635.19|188.33|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|635.19||||635.19|222.32|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|635.19||||635.19|188.33|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|635.19||||635.19|188.33|438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|635.19||||635.19||438.28|47.18
88241|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IDARUBICIN 1 MG/ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|635.19||||635.19||438.28|47.18
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|111.91||||111.91|93.8|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|111.91||||111.91|44.4|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111.91||||111.91|33.18|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|111.91||||111.91|52.6|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111.91||||111.91|0|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111.91||||111.91|55.96|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111.91||||111.91|70.5|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111.91||||111.91|33.18|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|111.91||||111.91|61.55|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|111.91||||111.91|77.22|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|111.91||||111.91|2.1|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111.91||||111.91|44.4|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111.91||||111.91|33.18|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111.91||||111.91|44.4|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111.91||||111.91|33.18|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|111.91||||111.91|33.18|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|111.91||||111.91|77.22|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111.91||||111.91|33.18|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|111.91||||111.91|39.17|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|111.91||||111.91|33.18|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111.91||||111.91|33.18|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111.91||||111.91|93.8|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111.91||||111.91|93.8|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111.91||||111.91||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|AARP [1000]|AARP [100000]|310||||310|187.6|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|310||||310||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|AETNA [1015]|AETNA [101529]|310||||310|88.8|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|310||||310|91.92|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|310||||310||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|310||||310||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BCBS UTHCT [115568]|310||||310|145.7|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|310||||310|0|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|310||||310|155|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|310||||310|195.3|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|310||||310|91.92|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|310||||310||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|CIGNA [1260]|CIGNA GWH [126023]|310||||310|170.5|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|310||||310|213.9|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|310||||310|2.1|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|310||||310||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|310||||310|88.8|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|310||||310|91.92|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|310||||310||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|310||||310|88.8|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|310||||310|91.92|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|310||||310|91.92|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|310||||310|213.9|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|310||||310|91.92|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|Self-pay|Self-pay|310||||310|108.5|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|310||||310|91.92|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|310||||310|91.92|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|310||||310|187.6|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|310||||310||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|310||||310||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|310||||310|187.6|213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|310||||310||213.9|2.1
88376|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CISPLATIN 1 MG/ML INTRAVENOUS SOLUTION|200 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|310||||310||213.9|2.1
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|AARP [1000]|AARP [100000]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|AETNA [1015]|AETNA [101529]|2.93||||2.93|1.29|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.93||||2.93|0.87|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|BCBS [1155]|BCBS UTHCT [115568]|2.93||||2.93|1.38|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.93||||2.93|1.47|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.93||||2.93|1.47|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.93||||2.93|1.85|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.93||||2.93|0.87|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|CIGNA [1260]|CIGNA GWH [126023]|2.93||||2.93|1.61|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|2.93||||2.93|2.02|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.93||||2.93|1.47|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.93||||2.93|1.29|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.93||||2.93|0.87|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.93||||2.93|1.29|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.93||||2.93|0.87|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.93||||2.93|0.87|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|2.93||||2.93|2.02|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.93||||2.93|0.87|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|Self-pay|Self-pay|2.93||||2.93|1.03|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.93||||2.93|0.87|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.93||||2.93|0.87|2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.93||||2.93||2.02|0.87
88504|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACETAMINOPHEN 325 MG/10.15 ML ORAL SUSPENSION|10.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.93||||2.93||2.02|0.87
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|AARP [1000]|AARP [100000]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|AETNA [1015]|AETNA [101529]|5138.25||||5138.25|3594.6|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5138.25||||5138.25|1523.49|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|BCBS [1155]|BCBS UTHCT [115568]|5138.25||||5138.25|2414.98|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5138.25||||5138.25|0|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5138.25||||5138.25|2569.13|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5138.25||||5138.25|3237.1|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5138.25||||5138.25|1523.49|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|CIGNA [1260]|CIGNA GWH [126023]|5138.25||||5138.25|2569.13|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|5138.25||||5138.25|3545.39|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5138.25||||5138.25|127.65|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5138.25||||5138.25|3594.6|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5138.25||||5138.25|1523.49|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5138.25||||5138.25|3594.6|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5138.25||||5138.25|1523.49|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|5138.25||||5138.25|1523.49|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|5138.25||||5138.25|3545.39|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5138.25||||5138.25|1523.49|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|Self-pay|Self-pay|5138.25||||5138.25|1798.39|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5138.25||||5138.25|1523.49|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5138.25||||5138.25|1523.49|3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5138.25||||5138.25||3594.6|127.65
88652|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 15 MG INTRAVENOUS SOLUTION|15 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5138.25||||5138.25||3594.6|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|AARP [1000]|AARP [100000]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|AETNA [1015]|AETNA [101529]|15414.75||||15414.75|10783.8|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15414.75||||15414.75|4570.47|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|BCBS [1155]|BCBS UTHCT [115568]|15414.75||||15414.75|7244.93|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15414.75||||15414.75|0|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15414.75||||15414.75|7707.38|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15414.75||||15414.75|9711.29|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15414.75||||15414.75|4570.47|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|CIGNA [1260]|CIGNA GWH [126023]|15414.75||||15414.75|7707.38|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|15414.75||||15414.75|10636.18|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15414.75||||15414.75|127.65|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15414.75||||15414.75|10783.8|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15414.75||||15414.75|4570.47|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15414.75||||15414.75|10783.8|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15414.75||||15414.75|4570.47|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|15414.75||||15414.75|4570.47|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|15414.75||||15414.75|10636.18|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15414.75||||15414.75|4570.47|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|Self-pay|Self-pay|15414.75||||15414.75|5395.16|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15414.75||||15414.75|4570.47|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15414.75||||15414.75|4570.47|10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15414.75||||15414.75||10783.8|127.65
88653|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IXABEPILONE 45 MG INTRAVENOUS SOLUTION|45 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15414.75||||15414.75||10783.8|127.65
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.1||||0.1|0.04|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.1||||0.1|0.03|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.1||||0.1|0.05|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.1||||0.1|0.05|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.1||||0.1|0.05|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.1||||0.1|0.06|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.1||||0.1|0.03|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.1||||0.1|0.06|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.1||||0.1|0.07|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.1||||0.1|0.05|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.1||||0.1|0.04|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.1||||0.1|0.03|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.1||||0.1|0.04|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.1||||0.1|0.03|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.1||||0.1|0.03|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.1||||0.1|0.07|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.1||||0.1|0.03|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|Self-pay|Self-pay|0.1||||0.1|0.03|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.1||||0.1|0.03|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.1||||0.1|0.03|0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.1||||0.1||0.07|0.03
8872|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC GLUCONATE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.1||||0.1||0.07|0.03
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|AARP [1000]|AARP [100000]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|AETNA [1015]|AETNA [101529]|6.01||||6.01|2.65|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.01||||6.01|1.78|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|BCBS [1155]|BCBS UTHCT [115568]|6.01||||6.01|2.82|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.01||||6.01|3.01|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.01||||6.01|3.01|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.01||||6.01|3.79|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.01||||6.01|1.78|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|CIGNA [1260]|CIGNA GWH [126023]|6.01||||6.01|3.31|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|GROUP PENSION ADMIN [1450]|GPA [145000]|6.01||||6.01|4.15|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.01||||6.01|3.01|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.01||||6.01|2.65|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.01||||6.01|1.78|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.01||||6.01|2.65|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.01||||6.01|1.78|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.01||||6.01|1.78|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|PHCS [1780]|PHCS MULTIPLAN [178000]|6.01||||6.01|4.15|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.01||||6.01|1.78|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|Self-pay|Self-pay|6.01||||6.01|2.1|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.01||||6.01|1.78|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.01||||6.01|1.78|4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.01||||6.01||4.15|1.78
8874|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC OXIDE 20 % TOPICAL OINTMENT|57 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.01||||6.01||4.15|1.78
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.11||||0.11|0.05|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.11||||0.11|0.03|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.11||||0.11|0.05|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.11||||0.11|0.06|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.11||||0.11|0.06|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.11||||0.11|0.07|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.11||||0.11|0.03|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.11||||0.11|0.06|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.11||||0.11|0.08|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.11||||0.11|0.06|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.11||||0.11|0.05|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.11||||0.11|0.03|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.11||||0.11|0.05|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.11||||0.11|0.03|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.11||||0.11|0.03|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.11||||0.11|0.08|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.11||||0.11|0.03|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|Self-pay|Self-pay|0.11||||0.11|0.04|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.11||||0.11|0.03|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.11||||0.11|0.03|0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.11||||0.11||0.08|0.03
8880|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.11||||0.11||0.08|0.03
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|AARP [1000]|AARP [100000]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.13||||0.13|0.06|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.13||||0.13|0.04|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.13||||0.13|0.06|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.13||||0.13|0.07|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.13||||0.13|0.07|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.13||||0.13|0.08|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.13||||0.13|0.04|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.13||||0.13|0.07|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.13||||0.13|0.09|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.13||||0.13|0.07|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.13||||0.13|0.06|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.13||||0.13|0.04|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.13||||0.13|0.06|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.13||||0.13|0.04|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.13||||0.13|0.04|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.13||||0.13|0.09|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.13||||0.13|0.04|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|Self-pay|Self-pay|0.13||||0.13|0.05|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.13||||0.13|0.04|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.13||||0.13|0.04|0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.13||||0.13||0.09|0.04
8881|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ZINC SULFATE 50 MG ZINC (220 MG) TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.13||||0.13||0.09|0.04
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|16.63||||16.63|7.33|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.63||||16.63|4.93|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|16.63||||16.63|7.82|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.63||||16.63|8.32|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.63||||16.63|8.32|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.63||||16.63|10.48|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.63||||16.63|4.93|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|16.63||||16.63|9.15|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|16.63||||16.63|11.47|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.63||||16.63|8.32|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.63||||16.63|7.33|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.63||||16.63|4.93|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.63||||16.63|7.33|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.63||||16.63|4.93|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.63||||16.63|4.93|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|16.63||||16.63|11.47|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.63||||16.63|4.93|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|Self-pay|Self-pay|16.63||||16.63|5.82|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.63||||16.63|4.93|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.63||||16.63|4.93|11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.63||||16.63||11.47|4.93
89284|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.63||||16.63||11.47|4.93
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|16.32||||16.32|7.2|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.32||||16.32|4.84|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|16.32||||16.32|7.67|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.32||||16.32|8.16|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.32||||16.32|8.16|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.32||||16.32|10.28|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.32||||16.32|4.84|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|16.32||||16.32|8.98|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|16.32||||16.32|11.26|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.32||||16.32|8.16|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.32||||16.32|7.2|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.32||||16.32|4.84|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.32||||16.32|7.2|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.32||||16.32|4.84|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.32||||16.32|4.84|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|16.32||||16.32|11.26|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.32||||16.32|4.84|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|16.32||||16.32|5.71|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.32||||16.32|4.84|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.32||||16.32|4.84|11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.32||||16.32||11.26|4.84
89285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|NEBIVOLOL 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.32||||16.32||11.26|4.84
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|44.23||||44.23|19.51|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.23||||44.23|13.11|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|44.23||||44.23|20.79|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.23||||44.23|22.12|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.23||||44.23|22.12|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.23||||44.23|27.86|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.23||||44.23|13.11|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|44.23||||44.23|24.33|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|44.23||||44.23|30.52|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|44.23||||44.23|22.12|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.23||||44.23|19.51|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.23||||44.23|13.11|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.23||||44.23|19.51|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.23||||44.23|13.11|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|44.23||||44.23|13.11|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|44.23||||44.23|30.52|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.23||||44.23|13.11|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|Self-pay|Self-pay|44.23||||44.23|15.48|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|44.23||||44.23|13.11|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.23||||44.23|13.11|30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.23||||44.23||30.52|13.11
89346|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOPIDOGREL 300 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.23||||44.23||30.52|13.11
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|2385.95||||2385.95|764.2|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2385.95||||2385.95|756.78|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|2385.95||||2385.95|1737.84|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2385.95||||2385.95|707.43|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2385.95||||2385.95|749.29|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2385.95||||2385.95|749.29|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|2385.95||||2385.95|1121.4|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2385.95||||2385.95|0|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2385.95||||2385.95|1192.98|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2385.95||||2385.95|1503.15|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2385.95||||2385.95|707.43|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2385.95||||2385.95|749.29|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|2385.95||||2385.95|1192.98|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2385.95||||2385.95|1646.31|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2385.95||||2385.95|91.49|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2385.95||||2385.95|749.29|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2385.95||||2385.95|1737.84|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2385.95||||2385.95|707.43|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2385.95||||2385.95|749.29|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2385.95||||2385.95|1737.84|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2385.95||||2385.95|707.43|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|2385.95||||2385.95|707.43|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2385.95||||2385.95|1646.31|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2385.95||||2385.95|707.43|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|2385.95||||2385.95|835.08|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2385.95||||2385.95|707.43|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2385.95||||2385.95|707.43|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2385.95||||2385.95|764.2|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2385.95||||2385.95|749.29|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2385.95||||2385.95|749.29|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2385.95||||2385.95|764.2|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2385.95||||2385.95|749.29|1737.84|91.49
89350|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PEMETREXED 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2385.95||||2385.95|1498.58|1737.84|91.49
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AARP [1000]|AARP [100000]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AETNA [1015]|AETNA [101529]|124.06||||124.06|54.71|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|124.06||||124.06|36.78|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS [1155]|BCBS UTHCT [115568]|124.06||||124.06|58.31|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|124.06||||124.06|62.03|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|124.06||||124.06|62.03|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|124.06||||124.06|78.16|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|124.06||||124.06|36.78|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|CIGNA [1260]|CIGNA GWH [126023]|124.06||||124.06|68.23|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|GROUP PENSION ADMIN [1450]|GPA [145000]|124.06||||124.06|85.6|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|HEALTHFIRST [2395]|HEALTHFIRST [239500]|124.06||||124.06|62.03|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|MAILHANDLERS [1595]|MAILHANDLERS [159500]|124.06||||124.06|54.71|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|124.06||||124.06|36.78|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|124.06||||124.06|54.71|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|124.06||||124.06|36.78|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|PENDING SSI [1616]|PENDING SSI RCA [161601]|124.06||||124.06|36.78|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|PHCS [1780]|PHCS MULTIPLAN [178000]|124.06||||124.06|85.6|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|124.06||||124.06|36.78|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|Self-pay|Self-pay|124.06||||124.06|43.42|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|124.06||||124.06|36.78|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|124.06||||124.06|36.78|85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|UMR [2035]|UMR UNITED HEALTHCARE [203502]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|124.06||||124.06||85.6|36.78
89570|ERX|0250 - PHARMACY-GENERAL|THROMBIN (RECOMBINANT) 5,000 UNIT TOPICAL SOLUTION|5,000 Units|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|124.06||||124.06||85.6|36.78
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.83||||0.83|0.37|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.83||||0.83|0.25|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.83||||0.83|0.39|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.83||||0.83|0.42|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.83||||0.83|0.42|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.83||||0.83|0.52|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.83||||0.83|0.25|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.83||||0.83|0.46|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.83||||0.83|0.57|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.83||||0.83|0.42|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.83||||0.83|0.37|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.83||||0.83|0.25|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.83||||0.83|0.37|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.83||||0.83|0.25|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.83||||0.83|0.25|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.83||||0.83|0.57|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.83||||0.83|0.25|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|Self-pay|Self-pay|0.83||||0.83|0.29|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.83||||0.83|0.25|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.83||||0.83|0.25|0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.83||||0.83||0.57|0.25
8958|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUTALBITAL-ACETAMINOPHEN-CAFFEINE 50 MG-325 MG-40 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.83||||0.83||0.57|0.25
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.06||||1.06|0.47|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.06||||1.06|0.31|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.06||||1.06|0.5|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.06||||1.06|0.53|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.06||||1.06|0.53|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.06||||1.06|0.67|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.06||||1.06|0.31|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.06||||1.06|0.58|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.06||||1.06|0.73|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.06||||1.06|0.53|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.06||||1.06|0.47|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.06||||1.06|0.31|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.06||||1.06|0.47|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.06||||1.06|0.31|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.06||||1.06|0.31|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.06||||1.06|0.73|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.06||||1.06|0.31|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.06||||1.06|0.37|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.06||||1.06|0.31|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.06||||1.06|0.31|0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.06||||1.06||0.73|0.31
8969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 200 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.06||||1.06||0.73|0.31
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.83||||2.83|1.25|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.83||||2.83|0.84|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.83||||2.83|1.33|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.83||||2.83|1.42|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.83||||2.83|1.42|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.83||||2.83|1.78|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.83||||2.83|0.84|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.83||||2.83|1.56|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.83||||2.83|1.95|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.83||||2.83|1.42|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.83||||2.83|1.25|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.83||||2.83|0.84|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.83||||2.83|1.25|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.83||||2.83|0.84|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.83||||2.83|0.84|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.83||||2.83|1.95|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.83||||2.83|0.84|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|Self-pay|Self-pay|2.83||||2.83|0.99|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.83||||2.83|0.84|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.83||||2.83|0.84|1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.83||||2.83||1.95|0.84
8972|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ACYCLOVIR 800 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.83||||2.83||1.95|0.84
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|358.67||||358.67|94.42|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|358.67||||358.67|105.95|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|358.67||||358.67|251.76|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|358.67||||358.67|106.35|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|358.67||||358.67|104.9|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|358.67||||358.67|104.9|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|358.67||||358.67|168.57|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|358.67||||358.67|0|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|358.67||||358.67|179.34|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|358.67||||358.67|225.96|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|358.67||||358.67|106.35|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|358.67||||358.67|104.9|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|358.67||||358.67|197.27|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|358.67||||358.67|247.48|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|358.67||||358.67|65.56|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|358.67||||358.67|104.9|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|358.67||||358.67|251.76|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|358.67||||358.67|106.35|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|358.67||||358.67|104.9|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|358.67||||358.67|251.76|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|358.67||||358.67|106.35|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|358.67||||358.67|106.35|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|358.67||||358.67|247.48|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|358.67||||358.67|106.35|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|358.67||||358.67|125.53|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|358.67||||358.67|106.35|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|358.67||||358.67|106.88|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|358.67||||358.67|94.42|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|358.67||||358.67|104.9|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|358.67||||358.67|104.9|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|358.67||||358.67|94.42|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|358.67||||358.67|104.9|251.76|65.56
8981|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 25 % INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|358.67||||358.67|209.8|251.76|65.56
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AARP [1000]|AARP [100000]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AETNA [1015]|AETNA [101529]|214.68||||214.68|125.88|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|214.68||||214.68|63.65|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BCBS UTHCT [115568]|214.68||||214.68|100.9|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|214.68||||214.68|0|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|214.68||||214.68|107.34|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|214.68||||214.68|135.25|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|214.68||||214.68|63.65|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|CIGNA [1260]|CIGNA GWH [126023]|214.68||||214.68|118.07|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|214.68||||214.68|148.13|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|214.68||||214.68|13.11|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|214.68||||214.68|125.88|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|214.68||||214.68|63.65|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|214.68||||214.68|125.88|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|214.68||||214.68|63.65|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|214.68||||214.68|63.65|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|214.68||||214.68|148.13|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|214.68||||214.68|63.65|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|Self-pay|Self-pay|214.68||||214.68|75.14|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|214.68||||214.68|63.65|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|214.68||||214.68|59|148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|214.68||||214.68||148.13|13.11
8982|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALBUMIN, HUMAN 5 % INTRAVENOUS SOLUTION|250 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|214.68||||214.68||148.13|13.11
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|AARP [1000]|AARP [100000]|27281.12||||27281.12|13640.56|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27281.12||||27281.12|8862.75|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|AETNA [1015]|AETNA [101529]|27281.12||||27281.12|21093.6|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27281.12||||27281.12|8088.85|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27281.12||||27281.12|8775|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27281.12||||27281.12|8775|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BCBS UTHCT [115568]|27281.12||||27281.12|12822.13|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27281.12||||27281.12|0|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27281.12||||27281.12|13640.56|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27281.12||||27281.12|17187.11|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27281.12||||27281.12|8088.85|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27281.12||||27281.12|8775|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|CIGNA [1260]|CIGNA GWH [126023]|27281.12||||27281.12|13640.56|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|27281.12||||27281.12|18823.97|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27281.12||||27281.12|109.29|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27281.12||||27281.12|8775|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27281.12||||27281.12|21093.6|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27281.12||||27281.12|8088.85|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27281.12||||27281.12|8775|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27281.12||||27281.12|21093.6|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27281.12||||27281.12|8088.85|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|27281.12||||27281.12|8088.85|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|27281.12||||27281.12|18823.97|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27281.12||||27281.12|8088.85|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|Self-pay|Self-pay|27281.12||||27281.12|9548.39|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27281.12||||27281.12|8088.85|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27281.12||||27281.12|8088.85|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27281.12||||27281.12|13640.56|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27281.12||||27281.12|8775|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27281.12||||27281.12|8775|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27281.12||||27281.12|13640.56|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27281.12||||27281.12|8775|21093.6|109.29
9002|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ALTEPLASE 100 MG INTRAVENOUS SOLUTION|100 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27281.12||||27281.12|17550|21093.6|109.29
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|AARP [1000]|AARP [100000]|339||||339|150|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|339||||339|122.39|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|AETNA [1015]|AETNA [101529]|339||||339|149.5|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|339||||339|100.51|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|339||||339|121.17|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|339||||339|121.17|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|BCBS [1155]|BCBS UTHCT [115568]|339||||339|159.33|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|339||||339|169.5|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|339||||339|169.5|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|339||||339|213.57|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|339||||339|100.51|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|339||||339|121.17|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|CIGNA [1260]|CIGNA GWH [126023]|339||||339|186.45|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|GROUP PENSION ADMIN [1450]|GPA [145000]|339||||339|233.91|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|339||||339|169.5|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|339||||339|129.78|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|339||||339|149.5|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|339||||339|100.51|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|339||||339|121.17|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|339||||339|149.5|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|339||||339|100.51|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|339||||339|100.51|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|PHCS [1780]|PHCS MULTIPLAN [178000]|339||||339|233.91|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|339||||339|100.51|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|Self-pay|Self-pay|339||||339|118.65|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|339||||339|100.51|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|339||||339|100.51|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|339||||339|150|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|339||||339|121.17|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|339||||339|121.17|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|339||||339|150|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|339||||339|121.17|242.35|100.51
90090791|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|339||||339|242.35|242.35|100.51
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|AARP [1000]|AARP [100000]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|AETNA [1015]|AETNA [101529]|201||||201|88.64|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|201||||201|59.6|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|BCBS [1155]|BCBS UTHCT [115568]|201||||201|94.47|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|201||||201|100.5|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|201||||201|100.5|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|201||||201|126.63|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|201||||201|59.6|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|CIGNA [1260]|CIGNA GWH [126023]|201||||201|110.55|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|201||||201|138.69|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|201||||201|100.5|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|201||||201|88.64|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|201||||201|59.6|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|201||||201|88.64|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|201||||201|59.6|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|201||||201|59.6|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|201||||201|138.69|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|201||||201|59.6|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|Self-pay|Self-pay|201||||201|70.35|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|201||||201|59.6|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|201||||201|59.6|138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|201||||201||138.69|59.6
90090792|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCHIATRIC DIAGNOSTIC EVAL W/MEDICAL SERVICES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|201||||201||138.69|59.6
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|AARP [1000]|AARP [100000]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|AETNA [1015]|AETNA [101529]|25||||25|11.03|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25||||25|7.41|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|BCBS [1155]|BCBS UTHCT [115568]|25||||25|11.75|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25||||25|12.5|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25||||25|12.5|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25||||25|15.75|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25||||25|7.41|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|CIGNA [1260]|CIGNA GWH [126023]|25||||25|13.75|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|25||||25|17.25|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25||||25|12.5|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25||||25|11.03|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25||||25|7.41|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25||||25|11.03|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25||||25|7.41|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|25||||25|7.41|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|25||||25|17.25|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25||||25|7.41|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|Self-pay|Self-pay|25||||25|8.75|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25||||25|7.41|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25||||25|7.41|17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25||||25||17.25|7.41
90090887|EAP|0900 - BEHAVIORAL HEALTH TREATMENTS/SERVICES (ALSO|HC PSYCH INTERPRETATION FAMILY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25||||25||17.25|7.41
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|AARP [1000]|AARP [100000]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|AETNA [1015]|AETNA [101529]|4.89||||4.89|2.16|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.89||||4.89|1.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BCBS UTHCT [115568]|4.89||||4.89|2.3|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.89||||4.89|2.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.89||||4.89|2.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.89||||4.89|3.08|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.89||||4.89|1.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|CIGNA [1260]|CIGNA GWH [126023]|4.89||||4.89|2.69|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.89||||4.89|3.37|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.89||||4.89|2.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.89||||4.89|2.16|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.89||||4.89|1.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.89||||4.89|2.16|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.89||||4.89|1.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.89||||4.89|1.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.89||||4.89|3.37|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.89||||4.89|1.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|Self-pay|Self-pay|4.89||||4.89|1.71|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.89||||4.89|1.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.89||||4.89|1.45|3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.89||||4.89||3.37|1.45
9014|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ALUMINUM-MAG HYDROXIDE-SIMETHICONE 400 MG-400 MG-40 MG/5 ML ORAL SUSP|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.89||||4.89||3.37|1.45
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|AARP [1000]|AARP [100000]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|AETNA [1015]|AETNA [101529]|105.4||||105.4|46.48|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105.4||||105.4|31.25|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|105.4||||105.4|49.54|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105.4||||105.4|52.7|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105.4||||105.4|52.7|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105.4||||105.4|66.4|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105.4||||105.4|31.25|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|105.4||||105.4|57.97|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|105.4||||105.4|72.73|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105.4||||105.4|52.7|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105.4||||105.4|46.48|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105.4||||105.4|31.25|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105.4||||105.4|46.48|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105.4||||105.4|31.25|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|105.4||||105.4|31.25|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|105.4||||105.4|72.73|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105.4||||105.4|31.25|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|Self-pay|Self-pay|105.4||||105.4|36.89|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105.4||||105.4|31.25|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105.4||||105.4|31.25|72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105.4||||105.4||72.73|31.25
9041|ERX|0250 - PHARMACY-GENERAL|AMINO ACIDS 3% WITH ELECTROLYTES AND GLYCERIN INTRAVENOUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105.4||||105.4||72.73|31.25
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|AARP [1000]|AARP [100000]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|AETNA [1015]|AETNA [101529]|133.18||||133.18|58.73|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|133.18||||133.18|39.49|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|BCBS [1155]|BCBS UTHCT [115568]|133.18||||133.18|62.59|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|133.18||||133.18|66.59|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|133.18||||133.18|66.59|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|133.18||||133.18|83.9|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|133.18||||133.18|39.49|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|CIGNA [1260]|CIGNA GWH [126023]|133.18||||133.18|73.25|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|133.18||||133.18|91.89|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|133.18||||133.18|66.59|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|133.18||||133.18|58.73|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|133.18||||133.18|39.49|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|133.18||||133.18|58.73|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|133.18||||133.18|39.49|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|133.18||||133.18|39.49|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|133.18||||133.18|91.89|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|133.18||||133.18|39.49|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|Self-pay|Self-pay|133.18||||133.18|46.61|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|133.18||||133.18|39.49|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|133.18||||133.18|39.49|91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|133.18||||133.18||91.89|39.49
9063|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMINOCAPROIC ACID 500 MG TABLET|2 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|133.18||||133.18||91.89|39.49
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.15||||1.15|0.51|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.15||||1.15|0.34|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.15||||1.15|0.54|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.15||||1.15|0.58|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.15||||1.15|0.58|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.15||||1.15|0.72|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.15||||1.15|0.34|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.15||||1.15|0.63|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.15||||1.15|0.79|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.15||||1.15|0.58|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.15||||1.15|0.51|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.15||||1.15|0.34|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.15||||1.15|0.51|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.15||||1.15|0.34|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.15||||1.15|0.34|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.15||||1.15|0.79|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.15||||1.15|0.34|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|Self-pay|Self-pay|1.15||||1.15|0.4|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.15||||1.15|0.34|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.15||||1.15|0.34|0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.15||||1.15||0.79|0.34
9066|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMIODARONE 200 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.15||||1.15||0.79|0.34
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.34||||0.34|0.15|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.34||||0.34|0.1|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.34||||0.34|0.16|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.34||||0.34|0.17|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.34||||0.34|0.17|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.34||||0.34|0.21|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.34||||0.34|0.1|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.34||||0.34|0.19|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.34||||0.34|0.23|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.34||||0.34|0.17|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.34||||0.34|0.15|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.34||||0.34|0.1|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.34||||0.34|0.15|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.34||||0.34|0.1|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.34||||0.34|0.1|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.34||||0.34|0.23|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.34||||0.34|0.1|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.34||||0.34|0.12|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.34||||0.34|0.1|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.34||||0.34|0.1|0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.34||||0.34||0.23|0.1
9069|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.34||||0.34||0.23|0.1
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.07||||0.07|0.03|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.07||||0.07|0.02|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.07||||0.07|0.03|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.07||||0.07|0.04|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.07||||0.07|0.04|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.07||||0.07|0.04|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.07||||0.07|0.02|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.07||||0.07|0.04|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.07||||0.07|0.05|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.07||||0.07|0.04|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.07||||0.07|0.03|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.07||||0.07|0.02|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.07||||0.07|0.03|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.07||||0.07|0.02|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.07||||0.07|0.02|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.07||||0.07|0.05|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.07||||0.07|0.02|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.07||||0.07|0.02|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.07||||0.07|0.02|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.07||||0.07|0.02|0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.07||||0.07||0.05|0.02
9071|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|AMLODIPINE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.07||||0.07||0.05|0.02
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AARP [1000]|AARP [100000]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AETNA [1015]|AETNA [101529]|20.15||||20.15|6.62|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|20.15||||20.15|5.97|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS [1155]|BCBS UTHCT [115568]|20.15||||20.15|9.47|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|20.15||||20.15|0|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|20.15||||20.15|10.08|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|20.15||||20.15|12.69|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|20.15||||20.15|5.97|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|CIGNA [1260]|CIGNA GWH [126023]|20.15||||20.15|11.08|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|20.15||||20.15|13.9|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|20.15||||20.15|3.08|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|20.15||||20.15|6.62|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|20.15||||20.15|5.97|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|20.15||||20.15|6.62|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|20.15||||20.15|5.97|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|20.15||||20.15|5.97|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|20.15||||20.15|13.9|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|20.15||||20.15|5.97|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|Self-pay|Self-pay|20.15||||20.15|7.05|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|20.15||||20.15|5.97|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|20.15||||20.15|5.97|13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|20.15||||20.15||13.9|3.08
9083|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION|1.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|20.15||||20.15||13.9|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AARP [1000]|AARP [100000]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AETNA [1015]|AETNA [101529]|27.9||||27.9|13.25|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.9||||27.9|8.27|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS [1155]|BCBS UTHCT [115568]|27.9||||27.9|13.11|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.9||||27.9|0|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.9||||27.9|13.95|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.9||||27.9|17.58|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.9||||27.9|8.27|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|CIGNA [1260]|CIGNA GWH [126023]|27.9||||27.9|15.35|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|GROUP PENSION ADMIN [1450]|GPA [145000]|27.9||||27.9|19.25|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.9||||27.9|3.08|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.9||||27.9|13.25|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.9||||27.9|8.27|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.9||||27.9|13.25|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.9||||27.9|8.27|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.9||||27.9|8.27|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|PHCS [1780]|PHCS MULTIPLAN [178000]|27.9||||27.9|19.25|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.9||||27.9|8.27|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|Self-pay|Self-pay|27.9||||27.9|9.76|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.9||||27.9|8.27|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.9||||27.9|8.27|19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.9||||27.9||19.25|3.08
9084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION|3 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.9||||27.9||19.25|3.08
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|105.71||||105.71|46.62|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|105.71||||105.71|31.34|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|105.71||||105.71|49.68|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|105.71||||105.71|52.86|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|105.71||||105.71|52.86|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|105.71||||105.71|66.6|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|105.71||||105.71|31.34|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|105.71||||105.71|58.14|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|105.71||||105.71|72.94|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|105.71||||105.71|52.86|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|105.71||||105.71|46.62|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|105.71||||105.71|31.34|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|105.71||||105.71|46.62|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|105.71||||105.71|31.34|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|105.71||||105.71|31.34|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|105.71||||105.71|72.94|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|105.71||||105.71|31.34|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|Self-pay|Self-pay|105.71||||105.71|37|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|105.71||||105.71|31.34|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|105.71||||105.71|31.34|72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|105.71||||105.71||72.94|31.34
91033|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 720 ELISA UNIT/0.5 ML IM SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|105.71||||105.71||72.94|31.34
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|AARP [1000]|AARP [100000]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|AETNA [1015]|AETNA [101529]|108.08||||108.08|47.66|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|108.08||||108.08|32.05|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|108.08||||108.08|50.8|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|108.08||||108.08|54.04|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|108.08||||108.08|54.04|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|108.08||||108.08|68.09|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|108.08||||108.08|32.05|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|108.08||||108.08|59.44|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|108.08||||108.08|74.58|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|108.08||||108.08|54.04|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|108.08||||108.08|47.66|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|108.08||||108.08|32.05|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|108.08||||108.08|47.66|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|108.08||||108.08|32.05|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|108.08||||108.08|32.05|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|108.08||||108.08|74.58|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|108.08||||108.08|32.05|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|Self-pay|Self-pay|108.08||||108.08|37.83|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|108.08||||108.08|32.05|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|108.08||||108.08|32.05|74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|108.08||||108.08||74.58|32.05
91045|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|HEPATITIS A VIRUS VACCINE (PF) 25 UNIT/0.5 ML INTRAMUSCULAR SUSPENSION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|108.08||||108.08||74.58|32.05
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|116.32||||116.32|116.32|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|116.32||||116.32||116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|116.32||||116.32|33|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|116.32||||116.32|34.49|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|116.32||||116.32||116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|116.32||||116.32||116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|116.32||||116.32|54.67|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|116.32||||116.32|0|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|116.32||||116.32|58.16|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|116.32||||116.32|73.28|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|116.32||||116.32|34.49|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|116.32||||116.32||116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|116.32||||116.32|63.98|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|116.32||||116.32|80.26|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|116.32||||116.32|3.06|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|116.32||||116.32||116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|116.32||||116.32|33|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|116.32||||116.32|34.49|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|116.32||||116.32||116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|116.32||||116.32|33|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|116.32||||116.32|34.49|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|116.32||||116.32|34.49|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|116.32||||116.32|80.26|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|116.32||||116.32|34.49|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|116.32||||116.32|40.71|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|116.32||||116.32|34.49|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|116.32||||116.32|34.49|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|116.32||||116.32|116.32|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|116.32||||116.32||116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|116.32||||116.32||116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|116.32||||116.32|116.32|116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|116.32||||116.32||116.32|3.06
91054|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|IRINOTECAN 100 MG/5 ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|116.32||||116.32||116.32|3.06
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AARP [1000]|AARP [100000]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AETNA [1015]|AETNA [101529]|3.3||||3.3|1.46|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.3||||3.3|0.98|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.3||||3.3|1.55|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.3||||3.3|1.65|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.3||||3.3|1.65|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.3||||3.3|2.08|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.3||||3.3|0.98|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.3||||3.3|1.82|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.3||||3.3|2.28|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.3||||3.3|1.65|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.3||||3.3|1.46|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.3||||3.3|0.98|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.3||||3.3|1.46|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.3||||3.3|0.98|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.3||||3.3|0.98|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.3||||3.3|2.28|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.3||||3.3|0.98|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|Self-pay|Self-pay|3.3||||3.3|1.15|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.3||||3.3|0.98|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.3||||3.3|0.98|2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.3||||3.3||2.28|0.98
91073|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DESVENLAFAXINE SUCCINATE ER 50 MG TABLET,EXTENDED RELEASE 24 HR|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.3||||3.3||2.28|0.98
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|13.95||||13.95|3.98|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.95||||13.95|4.14|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|13.95||||13.95|6.56|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.95||||13.95|0|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.95||||13.95|6.98|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.95||||13.95|8.79|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.95||||13.95|4.14|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|13.95||||13.95|7.67|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.95||||13.95|9.63|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.95||||13.95|0.93|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.95||||13.95|3.98|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.95||||13.95|4.14|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.95||||13.95|3.98|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.95||||13.95|4.14|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.95||||13.95|4.14|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.95||||13.95|9.63|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.95||||13.95|4.14|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|13.95||||13.95|4.88|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.95||||13.95|4.14|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.95||||13.95|4.14|9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.95||||13.95||9.63|0.93
91278|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 50 MCG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.95||||13.95||9.63|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AARP [1000]|AARP [100000]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AETNA [1015]|AETNA [101529]|23.12||||23.12|5.98|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.12||||23.12|6.86|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS [1155]|BCBS UTHCT [115568]|23.12||||23.12|10.87|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.12||||23.12|0|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.12||||23.12|11.56|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.12||||23.12|14.57|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.12||||23.12|6.86|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|CIGNA [1260]|CIGNA GWH [126023]|23.12||||23.12|12.72|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23.12||||23.12|15.95|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.12||||23.12|0.93|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.12||||23.12|5.98|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.12||||23.12|6.86|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.12||||23.12|5.98|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.12||||23.12|6.86|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.12||||23.12|6.86|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23.12||||23.12|15.95|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.12||||23.12|6.86|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|Self-pay|Self-pay|23.12||||23.12|8.09|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.12||||23.12|6.86|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.12||||23.12|6.86|15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.12||||23.12||15.95|0.93
91279|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 100 MCG/ML INJECTION SOLUTION|0.75 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.12||||23.12||15.95|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|154.04||||154.04|39.84|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|154.04||||154.04|45.67|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|154.04||||154.04|72.4|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|154.04||||154.04|0|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|154.04||||154.04|77.02|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|154.04||||154.04|97.05|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|154.04||||154.04|45.67|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|154.04||||154.04|84.72|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|154.04||||154.04|106.29|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|154.04||||154.04|0.93|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|154.04||||154.04|39.84|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|154.04||||154.04|45.67|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|154.04||||154.04|39.84|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|154.04||||154.04|45.67|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|154.04||||154.04|45.67|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|154.04||||154.04|106.29|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|154.04||||154.04|45.67|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|154.04||||154.04|53.91|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|154.04||||154.04|45.67|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|154.04||||154.04|45.67|106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|154.04||||154.04||106.29|0.93
91281|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OCTREOTIDE ACETATE 500 MCG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|154.04||||154.04||106.29|0.93
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AARP [1000]|AARP [100000]|9.38||||9.38|5.92|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.38||||9.38||6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|9.38||||9.38|5.57|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.38||||9.38|2.78|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.38||||9.38||6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.38||||9.38||6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|9.38||||9.38|4.41|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.38||||9.38|0|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.38||||9.38|4.69|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.38||||9.38|5.91|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.38||||9.38|2.78|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.38||||9.38||6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|9.38||||9.38|5.16|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.38||||9.38|6.47|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.38||||9.38|0.49|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.38||||9.38||6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.38||||9.38|5.57|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.38||||9.38|2.78|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.38||||9.38||6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.38||||9.38|5.57|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.38||||9.38|2.78|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.38||||9.38|2.78|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.38||||9.38|6.47|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.38||||9.38|2.78|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|Self-pay|Self-pay|9.38||||9.38|3.28|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.38||||9.38|2.78|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.38||||9.38|2.78|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.38||||9.38|5.92|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.38||||9.38||6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.38||||9.38||6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.38||||9.38|5.92|6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.38||||9.38||6.47|0.49
91349|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|KETOROLAC 60 MG/2 ML INTRAMUSCULAR SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.38||||9.38||6.47|0.49
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AARP [1000]|AARP [100000]|775.78||||775.78|262.4|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|775.78||||775.78||568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AETNA [1015]|AETNA [101529]|775.78||||775.78|568.13|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|775.78||||775.78|230.02|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|775.78||||775.78||568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|775.78||||775.78||568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BCBS UTHCT [115568]|775.78||||775.78|364.62|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|775.78||||775.78|0|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|775.78||||775.78|387.89|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|775.78||||775.78|488.74|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|775.78||||775.78|230.02|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|775.78||||775.78||568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|CIGNA [1260]|CIGNA GWH [126023]|775.78||||775.78|387.89|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|775.78||||775.78|535.29|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|775.78||||775.78|74.21|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|775.78||||775.78||568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|775.78||||775.78|568.13|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|775.78||||775.78|230.02|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|775.78||||775.78||568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|775.78||||775.78|568.13|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|775.78||||775.78|230.02|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|775.78||||775.78|230.02|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|775.78||||775.78|535.29|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|775.78||||775.78|230.02|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|Self-pay|Self-pay|775.78||||775.78|271.52|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|775.78||||775.78|230.02|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|775.78||||775.78|230.02|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|775.78||||775.78|262.4|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|775.78||||775.78||568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|775.78||||775.78||568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|775.78||||775.78|262.4|568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|775.78||||775.78||568.13|74.21
91408|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|REGADENOSON 0.4 MG/5 ML INTRAVENOUS SYRINGE|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|775.78||||775.78||568.13|74.21
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|AARP [1000]|AARP [100000]|25||||25|0|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25||||25||25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|AETNA [1015]|AETNA [101529]|25||||25|25|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25||||25|7.41|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25||||25||25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25||||25||25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|BCBS [1155]|BCBS UTHCT [115568]|25||||25|11.75|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25||||25|12.5|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25||||25|12.5|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25||||25|15.75|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25||||25|7.41|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25||||25||25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|CIGNA [1260]|CIGNA GWH [126023]|25||||25|13.75|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|25||||25|17.25|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25||||25|12.5|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25||||25||25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25||||25|25|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25||||25|7.41|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25||||25||25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25||||25|25|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25||||25|7.41|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|25||||25|7.41|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|25||||25|17.25|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25||||25|7.41|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|Self-pay|Self-pay|25||||25|8.75|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25||||25|7.41|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25||||25|7.41|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25||||25|0|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25||||25||25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25||||25||25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25||||25|0|25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25||||25||25|7.41
91490785|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH INTERACTIVE COMPLEXITY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25||||25||25|7.41
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|AARP [1000]|AARP [100000]|233||||233|0|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|233||||233|122.39|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|AETNA [1015]|AETNA [101529]|233||||233|233|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|233||||233|69.08|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|233||||233|121.17|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|233||||233|121.17|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|BCBS [1155]|BCBS UTHCT [115568]|233||||233|109.51|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|233||||233|116.5|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|233||||233|116.5|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|233||||233|146.79|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|233||||233|69.08|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|233||||233|121.17|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|CIGNA [1260]|CIGNA GWH [126023]|233||||233|128.15|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|233||||233|160.77|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|233||||233|116.5|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|233||||233|129.78|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|233||||233|233|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|233||||233|69.08|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|233||||233|121.17|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|233||||233|233|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|233||||233|69.08|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|233||||233|69.08|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|233||||233|160.77|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|233||||233|69.08|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|Self-pay|Self-pay|233||||233|81.55|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|233||||233|69.08|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|233||||233|69.08|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|233||||233|0|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|233||||233|121.17|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|233||||233|121.17|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|233||||233|0|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|233||||233|121.17|242.35|69.08
91490832|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 30 MIN W/PT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|233||||233|242.35|242.35|69.08
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|AARP [1000]|AARP [100000]|430||||430|0|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|430||||430|122.39|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|AETNA [1015]|AETNA [101529]|430||||430|430|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|430||||430|127.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|430||||430|121.17|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|430||||430|121.17|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|BCBS [1155]|BCBS UTHCT [115568]|430||||430|202.1|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|430||||430|215|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|430||||430|215|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|430||||430|270.9|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|430||||430|127.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|430||||430|121.17|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|CIGNA [1260]|CIGNA GWH [126023]|430||||430|236.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|430||||430|296.7|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|430||||430|215|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|430||||430|129.78|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|430||||430|430|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|430||||430|127.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|430||||430|121.17|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|430||||430|430|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|430||||430|127.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|430||||430|127.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|430||||430|296.7|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|430||||430|127.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|Self-pay|Self-pay|430||||430|150.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|430||||430|127.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|430||||430|127.5|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|430||||430|0|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|430||||430|121.17|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|430||||430|121.17|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|430||||430|0|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|430||||430|121.17|430|121.17
91490834|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 45 MIN W/PT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|430||||430|242.35|430|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|AARP [1000]|AARP [100000]|563||||563|0|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|563||||563|122.39|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|AETNA [1015]|AETNA [101529]|563||||563|550|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|563||||563|166.93|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|563||||563|121.17|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|563||||563|121.17|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|BCBS [1155]|BCBS UTHCT [115568]|563||||563|264.61|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|563||||563|281.5|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|563||||563|281.5|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|563||||563|354.69|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|563||||563|166.93|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|563||||563|121.17|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|CIGNA [1260]|CIGNA GWH [126023]|563||||563|309.65|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|563||||563|388.47|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|563||||563|281.5|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|563||||563|129.78|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|563||||563|550|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|563||||563|166.93|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|563||||563|121.17|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|563||||563|550|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|563||||563|166.93|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|563||||563|166.93|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|563||||563|388.47|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|563||||563|166.93|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|Self-pay|Self-pay|563||||563|197.05|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|563||||563|166.93|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|563||||563|166.93|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|563||||563|0|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|563||||563|121.17|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|563||||563|121.17|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|563||||563|0|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|563||||563|121.17|550|121.17
91490837|EAP|0914 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER 60 MIN W/PT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|563||||563|242.35|550|121.17
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|AARP [1000]|AARP [100000]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|AETNA [1015]|AETNA [101529]|14928.24||||14928.24|7948.8|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14928.24||||14928.24|4426.22|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|BCBS [1155]|BCBS UTHCT [115568]|14928.24||||14928.24|7016.27|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14928.24||||14928.24|0|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14928.24||||14928.24|7464.12|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14928.24||||14928.24|9404.79|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14928.24||||14928.24|4426.22|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|CIGNA [1260]|CIGNA GWH [126023]|14928.24||||14928.24|7464.12|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|14928.24||||14928.24|10300.49|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14928.24||||14928.24|10.23|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14928.24||||14928.24|7948.8|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14928.24||||14928.24|4426.22|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14928.24||||14928.24|7948.8|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14928.24||||14928.24|4426.22|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|14928.24||||14928.24|4426.22|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|14928.24||||14928.24|10300.49|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14928.24||||14928.24|4426.22|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|Self-pay|Self-pay|14928.24||||14928.24|5224.88|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14928.24||||14928.24|4426.22|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14928.24||||14928.24|4426.22|10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14928.24||||14928.24||10300.49|10.23
91495|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CERTOLIZUMAB PEGOL 400 MG (200 MG X 2 VIALS) SUBCUTANEOUS KIT|400 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14928.24||||14928.24||10300.49|10.23
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|19.18||||19.18|8.46|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.18||||19.18|5.69|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|19.18||||19.18|9.01|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.18||||19.18|9.59|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.18||||19.18|9.59|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.18||||19.18|12.08|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.18||||19.18|5.69|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|19.18||||19.18|10.55|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|19.18||||19.18|13.23|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.18||||19.18|9.59|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.18||||19.18|8.46|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.18||||19.18|5.69|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.18||||19.18|8.46|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.18||||19.18|5.69|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.18||||19.18|5.69|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|19.18||||19.18|13.23|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.18||||19.18|5.69|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|Self-pay|Self-pay|19.18||||19.18|6.71|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.18||||19.18|5.69|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.18||||19.18|5.69|13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.18||||19.18||13.23|5.69
91534|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LUBIPROSTONE 8 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.18||||19.18||13.23|5.69
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|AARP [1000]|AARP [100000]|225||||225|0|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|225||||225|68.58|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|AETNA [1015]|AETNA [101529]|225||||225|225|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|225||||225|66.71|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|225||||225|67.9|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|225||||225|67.9|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|BCBS [1155]|BCBS UTHCT [115568]|225||||225|105.75|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|225||||225|112.5|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|225||||225|112.5|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|225||||225|141.75|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|225||||225|66.71|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|225||||225|67.9|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|CIGNA [1260]|CIGNA GWH [126023]|225||||225|123.75|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|225||||225|155.25|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|225||||225|112.5|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|225||||225|72.72|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|225||||225|225|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|225||||225|66.71|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|225||||225|67.9|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|225||||225|225|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|225||||225|66.71|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|225||||225|66.71|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|225||||225|155.25|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|225||||225|66.71|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|Self-pay|Self-pay|225||||225|78.75|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|225||||225|66.71|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|225||||225|66.71|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|225||||225|0|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|225||||225|67.9|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|225||||225|67.9|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|225||||225|0|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|225||||225|67.9|225|66.71
91590853|EAP|0915 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC GROUP PSYCH THERAPY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|225||||225|135.79|225|66.71
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|AARP [1000]|AARP [100000]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|AETNA [1015]|AETNA [101529]|25||||25|25|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25||||25|7.41|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|25||||25|11.75|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25||||25|12.5|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25||||25|12.5|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25||||25|15.75|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25||||25|7.41|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|25||||25|13.75|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|25||||25|17.25|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25||||25|12.5|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25||||25|25|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25||||25|7.41|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25||||25|25|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25||||25|7.41|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|25||||25|7.41|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|25||||25|17.25|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25||||25|7.41|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|Self-pay|Self-pay|25||||25|8.75|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25||||25|7.41|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25||||25|7.41|25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25||||25||25|7.41
91690838|EAP|0917 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY W/PATIENT W/E&M SRVCS 60 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25||||25||25|7.41
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|AARP [1000]|AARP [100000]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|AETNA [1015]|AETNA [101529]|212||||212|212|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|212||||212|62.86|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|BCBS [1155]|BCBS UTHCT [115568]|212||||212|99.64|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|212||||212|106|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|212||||212|106|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|212||||212|133.56|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|212||||212|62.86|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|CIGNA [1260]|CIGNA GWH [126023]|212||||212|116.6|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|212||||212|146.28|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|212||||212|106|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|212||||212|212|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|212||||212|62.86|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|212||||212|212|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|212||||212|62.86|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|212||||212|62.86|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|212||||212|146.28|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|212||||212|62.86|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|Self-pay|Self-pay|212||||212|74.2|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|212||||212|62.86|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|212||||212|62.86|212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|212||||212||212|62.86
91690839|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS INITIAL 60 MINUTES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|212||||212||212|62.86
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|AARP [1000]|AARP [100000]|126||||126|0|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|126||||126||126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|AETNA [1015]|AETNA [101529]|126||||126|126|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|126||||126|37.36|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|126||||126||126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|126||||126||126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|BCBS [1155]|BCBS UTHCT [115568]|126||||126|59.22|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|126||||126|63|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|126||||126|63|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|126||||126|79.38|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|126||||126|37.36|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|126||||126||126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|CIGNA [1260]|CIGNA GWH [126023]|126||||126|69.3|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|GROUP PENSION ADMIN [1450]|GPA [145000]|126||||126|86.94|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|126||||126|63|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|126||||126||126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|126||||126|126|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|126||||126|37.36|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|126||||126||126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|126||||126|126|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|126||||126|37.36|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|126||||126|37.36|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|PHCS [1780]|PHCS MULTIPLAN [178000]|126||||126|86.94|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|126||||126|37.36|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|Self-pay|Self-pay|126||||126|44.1|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|126||||126|37.36|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|126||||126|37.36|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|126||||126|0|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|126||||126||126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|126||||126||126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|126||||126|0|126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|126||||126||126|37.36
91690840|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOTHERAPY FOR CRISIS EACH ADDL 30 MINUTES|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|126||||126||126|37.36
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|AARP [1000]|AARP [100000]|471||||471|0|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|471||||471||471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|AETNA [1015]|AETNA [101529]|471||||471|471|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|471||||471|139.65|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|471||||471||471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|471||||471||471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|BCBS [1155]|BCBS UTHCT [115568]|471||||471|221.37|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|471||||471|235.5|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|471||||471|235.5|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|471||||471|296.73|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|471||||471|139.65|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|471||||471||471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|CIGNA [1260]|CIGNA GWH [126023]|471||||471|259.05|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|471||||471|324.99|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|471||||471|235.5|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|471||||471||471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|471||||471|471|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|471||||471|139.65|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|471||||471||471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|471||||471|471|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|471||||471|139.65|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|471||||471|139.65|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|471||||471|324.99|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|471||||471|139.65|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|Self-pay|Self-pay|471||||471|164.85|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|471||||471|139.65|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|471||||471|139.65|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|471||||471|0|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|471||||471||471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|471||||471||471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|471||||471|0|471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|471||||471||471|139.65
91690846|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCH THER FAMILY W/O PT PRSNT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|AARP [1000]|AARP [100000]|471||||471|0|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|AETNA [1015]|AETNA [101529]|471||||471|471|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|471||||471|139.65|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|471||||471|221.37|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|471||||471|235.5|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|471||||471|235.5|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|471||||471|296.73|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|471||||471|139.65|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|471||||471|259.05|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|471||||471|324.99|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|471||||471|235.5|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|471||||471|471|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|471||||471|139.65|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|471||||471|471|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|471||||471|139.65|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|471||||471|139.65|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|471||||471|324.99|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|471||||471|139.65|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|Self-pay|Self-pay|471||||471|164.85|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|471||||471|139.65|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|471||||471|139.65|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|471||||471|0|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|471||||471|0|471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|471||||471||471|139.65
91690847|EAP|0916 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC FAMILY PSYCH THRPY W/PT PRESENT 50 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|471||||471||471|139.65
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|AARP [1000]|AARP [100000]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|AETNA [1015]|AETNA [101529]|11.96||||11.96|5.27|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11.96||||11.96|3.55|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|BCBS [1155]|BCBS UTHCT [115568]|11.96||||11.96|5.62|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11.96||||11.96|5.98|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11.96||||11.96|5.98|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11.96||||11.96|7.53|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11.96||||11.96|3.55|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|CIGNA [1260]|CIGNA GWH [126023]|11.96||||11.96|6.58|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|GROUP PENSION ADMIN [1450]|GPA [145000]|11.96||||11.96|8.25|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11.96||||11.96|5.98|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11.96||||11.96|5.27|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11.96||||11.96|3.55|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11.96||||11.96|5.27|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11.96||||11.96|3.55|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|11.96||||11.96|3.55|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|PHCS [1780]|PHCS MULTIPLAN [178000]|11.96||||11.96|8.25|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11.96||||11.96|3.55|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|Self-pay|Self-pay|11.96||||11.96|4.19|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11.96||||11.96|3.55|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11.96||||11.96|3.55|8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11.96||||11.96||8.25|3.55
9175|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM|15 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11.96||||11.96||8.25|3.55
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|AARP [1000]|AARP [100000]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|AETNA [1015]|AETNA [101529]|391.48||||391.48|172.64|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|BCBS [1155]|BCBS UTHCT [115568]|391.48||||391.48|184|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|391.48||||391.48|195.74|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|391.48||||391.48|195.74|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|391.48||||391.48|246.63|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|CIGNA [1260]|CIGNA GWH [126023]|391.48||||391.48|215.31|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|391.48||||391.48|270.12|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|391.48||||391.48|195.74|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|391.48||||391.48|172.64|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|391.48||||391.48|172.64|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|391.48||||391.48|270.12|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|Self-pay|Self-pay|391.48||||391.48|137.02|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|AARP [1000]|AARP [100000]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|AETNA [1015]|AETNA [101529]|391.48||||391.48|172.64|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|BCBS [1155]|BCBS UTHCT [115568]|391.48||||391.48|184|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|391.48||||391.48|195.74|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|391.48||||391.48|195.74|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|391.48||||391.48|246.63|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|CIGNA [1260]|CIGNA GWH [126023]|391.48||||391.48|215.31|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|391.48||||391.48|270.12|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|391.48||||391.48|195.74|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|391.48||||391.48|172.64|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|391.48||||391.48|172.64|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|391.48||||391.48|270.12|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|Self-pay|Self-pay|391.48||||391.48|137.02|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|391.48||||391.48|116.07|270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|391.48||||391.48||270.12|116.07
91822|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROTAVIRUS VACCINE,LIVE, 89-12 STRAIN G1P(8) 10EXP6 CCID50/ML ORAL SUSP|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|391.48||||391.48||270.12|116.07
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|111.85||||111.85|49.33|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|111.85||||111.85|33.16|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BCBS UTHCT [115568]|111.85||||111.85|52.57|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|111.85||||111.85|55.93|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|111.85||||111.85|55.93|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|111.85||||111.85|70.47|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|111.85||||111.85|33.16|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA GWH [126023]|111.85||||111.85|61.52|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|111.85||||111.85|77.18|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|111.85||||111.85|55.93|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|111.85||||111.85|49.33|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|111.85||||111.85|33.16|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|111.85||||111.85|49.33|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|111.85||||111.85|33.16|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|111.85||||111.85|33.16|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|111.85||||111.85|77.18|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|111.85||||111.85|33.16|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|111.85||||111.85|39.15|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|111.85||||111.85|33.16|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|111.85||||111.85|33.16|77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|111.85||||111.85||77.18|33.16
9185|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|111.85||||111.85||77.18|33.16
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|227.27||||227.27|100.23|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|227.27||||227.27|67.39|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BCBS UTHCT [115568]|227.27||||227.27|106.82|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|227.27||||227.27|113.64|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|227.27||||227.27|113.64|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|227.27||||227.27|143.18|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|227.27||||227.27|67.39|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA GWH [126023]|227.27||||227.27|125|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|227.27||||227.27|156.82|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|227.27||||227.27|113.64|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|227.27||||227.27|100.23|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|227.27||||227.27|67.39|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|227.27||||227.27|100.23|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|227.27||||227.27|67.39|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|227.27||||227.27|67.39|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|227.27||||227.27|156.82|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|227.27||||227.27|67.39|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|227.27||||227.27|79.54|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|227.27||||227.27|67.39|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|227.27||||227.27|67.39|156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|227.27||||227.27||156.82|67.39
9186|ERX|0250 - PHARMACY-GENERAL|AZTREONAM 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|227.27||||227.27||156.82|67.39
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|AARP [1000]|AARP [100000]|346||||346|150|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|346||||346|238.58|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|AETNA [1015]|AETNA [101529]|346||||346|346|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|346||||346|102.59|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|346||||346|236.22|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|346||||346|236.22|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|BCBS [1155]|BCBS UTHCT [115568]|346||||346|162.62|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|346||||346|173|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|346||||346|173|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|346||||346|217.98|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|346||||346|102.59|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|346||||346|236.22|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|CIGNA [1260]|CIGNA GWH [126023]|346||||346|190.3|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|GROUP PENSION ADMIN [1450]|GPA [145000]|346||||346|238.74|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|346||||346|173|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|346||||346|252.99|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|346||||346|346|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|346||||346|102.59|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|346||||346|236.22|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|346||||346|346|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|346||||346|102.59|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|346||||346|102.59|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|PHCS [1780]|PHCS MULTIPLAN [178000]|346||||346|238.74|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|346||||346|102.59|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|Self-pay|Self-pay|346||||346|121.1|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|346||||346|102.59|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|346||||346|102.59|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|346||||346|150|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|346||||346|236.22|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|346||||346|236.22|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|346||||346|150|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|346||||346|236.22|472.43|102.59
91896116|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NEURO BEHAVIORAL STATUS EXAM-TOVA|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|346||||346|472.43|472.43|102.59
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|AARP [1000]|AARP [100000]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|AETNA [1015]|AETNA [101529]|430||||430|430|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|430||||430|127.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|BCBS [1155]|BCBS UTHCT [115568]|430||||430|202.1|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|430||||430|135.73|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|430||||430|215|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|430||||430|270.9|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|430||||430|127.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|CIGNA [1260]|CIGNA GWH [126023]|430||||430|236.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|430||||430|296.7|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|430||||430|215|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|430||||430|430|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|430||||430|127.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|430||||430|430|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|430||||430|127.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|430||||430|127.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|430||||430|296.7|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|430||||430|127.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|Self-pay|Self-pay|430||||430|150.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|430||||430|127.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|430||||430|127.5|430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|430||||430||430|127.5
91896130|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|430||||430||430|127.5
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|AARP [1000]|AARP [100000]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|AETNA [1015]|AETNA [101529]|364.89||||364.89|364.89|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|364.89||||364.89|108.19|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|BCBS [1155]|BCBS UTHCT [115568]|364.89||||364.89|171.5|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|364.89||||364.89|103.33|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|364.89||||364.89|182.45|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|364.89||||364.89|229.88|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|364.89||||364.89|108.19|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|CIGNA [1260]|CIGNA GWH [126023]|364.89||||364.89|200.69|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|364.89||||364.89|251.77|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|364.89||||364.89|182.45|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|364.89||||364.89|364.89|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|364.89||||364.89|108.19|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|364.89||||364.89|364.89|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|364.89||||364.89|108.19|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|364.89||||364.89|108.19|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|364.89||||364.89|251.77|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|364.89||||364.89|108.19|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|Self-pay|Self-pay|364.89||||364.89|127.71|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|364.89||||364.89|108.19|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|364.89||||364.89|108.19|364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|364.89||||364.89||364.89|103.33
91896131|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|364.89||||364.89||364.89|103.33
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|AARP [1000]|AARP [100000]|430||||430|150|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|430||||430|238.58|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|AETNA [1015]|AETNA [101529]|430||||430|430|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|430||||430|127.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|430||||430|236.22|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|430||||430|236.22|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|BCBS [1155]|BCBS UTHCT [115568]|430||||430|202.1|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|430||||430|165.86|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|430||||430|215|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|430||||430|270.9|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|430||||430|127.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|430||||430|236.22|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|CIGNA [1260]|CIGNA GWH [126023]|430||||430|236.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|430||||430|296.7|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|430||||430|215|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|430||||430|252.99|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|430||||430|430|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|430||||430|127.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|430||||430|236.22|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|430||||430|430|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|430||||430|127.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|430||||430|127.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|430||||430|296.7|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|430||||430|127.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|Self-pay|Self-pay|430||||430|150.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|430||||430|127.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|430||||430|127.5|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|430||||430|150|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|430||||430|236.22|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|430||||430|236.22|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|430||||430|150|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|430||||430|236.22|472.43|127.5
91896132|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP 1ST HOUR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|430||||430|472.43|472.43|127.5
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|AARP [1000]|AARP [100000]|299.07||||299.07|150|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|299.07||||299.07||299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|AETNA [1015]|AETNA [101529]|299.07||||299.07|299.07|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|299.07||||299.07|88.67|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|299.07||||299.07||299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|299.07||||299.07||299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|BCBS [1155]|BCBS UTHCT [115568]|299.07||||299.07|140.56|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|299.07||||299.07|102.02|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|299.07||||299.07|149.54|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|299.07||||299.07|188.41|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|299.07||||299.07|88.67|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|299.07||||299.07||299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|CIGNA [1260]|CIGNA GWH [126023]|299.07||||299.07|164.49|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|GROUP PENSION ADMIN [1450]|GPA [145000]|299.07||||299.07|206.36|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|299.07||||299.07|149.54|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|299.07||||299.07||299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|299.07||||299.07|299.07|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|299.07||||299.07|88.67|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|299.07||||299.07||299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|299.07||||299.07|299.07|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|299.07||||299.07|88.67|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|299.07||||299.07|88.67|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|PHCS [1780]|PHCS MULTIPLAN [178000]|299.07||||299.07|206.36|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|299.07||||299.07|88.67|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|Self-pay|Self-pay|299.07||||299.07|104.67|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|299.07||||299.07|88.67|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|299.07||||299.07|88.67|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|299.07||||299.07|150|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|299.07||||299.07||299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|299.07||||299.07||299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|299.07||||299.07|150|299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|299.07||||299.07||299.07|88.67
91896133|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC NRPSYC TST EVAL PHYS/QHP EA ADDL HOUR|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|299.07||||299.07||299.07|88.67
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|AARP [1000]|AARP [100000]|430||||430|150|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|430||||430|102.53|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|AETNA [1015]|AETNA [101529]|430||||430|430|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|430||||430|127.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|430||||430|101.52|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|430||||430|101.52|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|430||||430|202.1|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|430||||430|30.65|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|430||||430|215|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|430||||430|270.9|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|430||||430|127.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|430||||430|101.52|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|430||||430|236.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|430||||430|296.7|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|430||||430|215|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|430||||430|108.73|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|430||||430|430|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|430||||430|127.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|430||||430|101.52|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|430||||430|430|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|430||||430|127.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|430||||430|127.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|430||||430|296.7|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|430||||430|127.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|Self-pay|Self-pay|430||||430|150.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|430||||430|127.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|430||||430|127.5|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|430||||430|150|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|430||||430|101.52|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|430||||430|101.52|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|430||||430|150|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|430||||430|101.52|430|30.65
91896136|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP 1ST 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|430||||430|203.04|430|30.65
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|AARP [1000]|AARP [100000]|15.36||||15.36|15.36|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.36||||15.36||15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|AETNA [1015]|AETNA [101529]|15.36||||15.36|15.36|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.36||||15.36|4.55|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.36||||15.36||15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.36||||15.36||15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|15.36||||15.36|7.22|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.36||||15.36|15.36|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.36||||15.36|7.68|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.36||||15.36|9.68|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.36||||15.36|4.55|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.36||||15.36||15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|15.36||||15.36|8.45|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|15.36||||15.36|10.6|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.36||||15.36|7.68|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.36||||15.36||15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.36||||15.36|15.36|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.36||||15.36|4.55|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.36||||15.36||15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.36||||15.36|15.36|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.36||||15.36|4.55|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.36||||15.36|4.55|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|15.36||||15.36|10.6|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.36||||15.36|4.55|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|Self-pay|Self-pay|15.36||||15.36|5.38|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.36||||15.36|4.55|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.36||||15.36|4.55|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.36||||15.36|15.36|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.36||||15.36||15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.36||||15.36||15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.36||||15.36|15.36|15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.36||||15.36||15.36|4.55
91896137|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PSYCL/NRPSYC TST PHY/QHP EA ADDL 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.36||||15.36||15.36|4.55
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|AARP [1000]|AARP [100000]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|AETNA [1015]|AETNA [101529]|236||||236|236|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|236||||236|69.97|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|BCBS [1155]|BCBS UTHCT [115568]|236||||236|110.92|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|236||||236|118|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|236||||236|118|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|236||||236|148.68|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|236||||236|69.97|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|CIGNA [1260]|CIGNA GWH [126023]|236||||236|129.8|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|236||||236|162.84|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|236||||236|118|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|236||||236|236|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|236||||236|69.97|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|236||||236|236|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|236||||236|69.97|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|236||||236|69.97|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|236||||236|162.84|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|236||||236|69.97|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|Self-pay|Self-pay|236||||236|82.6|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|236||||236|69.97|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|236||||236|69.97|236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|236||||236||236|69.97
91896156|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV ASSMT/REASSESSMENT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|AARP [1000]|AARP [100000]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|AETNA [1015]|AETNA [101529]|236||||236|236|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|236||||236|69.97|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|236||||236|110.92|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|236||||236|118|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|236||||236|118|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|236||||236|148.68|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|236||||236|69.97|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|236||||236|129.8|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|236||||236|162.84|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|236||||236|118|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|236||||236|236|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|236||||236|69.97|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|236||||236|236|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|236||||236|69.97|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|236||||236|69.97|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|236||||236|162.84|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|236||||236|69.97|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|Self-pay|Self-pay|236||||236|82.6|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|236||||236|69.97|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|236||||236|69.97|236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|236||||236||236|69.97
91896158|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV 1ST 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|236||||236||236|69.97
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|AARP [1000]|AARP [100000]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|AETNA [1015]|AETNA [101529]|63||||63|63|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|63||||63|18.68|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|63||||63|29.61|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|63||||63|31.5|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|63||||63|31.5|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|63||||63|39.69|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|63||||63|18.68|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|63||||63|34.65|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|63||||63|43.47|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|63||||63|31.5|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|63||||63|63|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|63||||63|18.68|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|63||||63|63|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|63||||63|18.68|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|63||||63|18.68|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|63||||63|43.47|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|63||||63|18.68|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|Self-pay|Self-pay|63||||63|22.05|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|63||||63|18.68|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|63||||63|18.68|63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|63||||63||63|18.68
91896159|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ INDIV EA ADDL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|63||||63||63|18.68
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|AARP [1000]|AARP [100000]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|AETNA [1015]|AETNA [101529]|70||||70|70|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|70||||70|20.76|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|BCBS [1155]|BCBS UTHCT [115568]|70||||70|32.9|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|70||||70|4.82|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|70||||70|35|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|70||||70|44.1|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|70||||70|20.76|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|CIGNA [1260]|CIGNA GWH [126023]|70||||70|38.5|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|70||||70|48.3|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|70||||70|35|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|70||||70|70|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|70||||70|20.76|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|70||||70|70|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|70||||70|20.76|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|70||||70|20.76|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|70||||70|48.3|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|70||||70|20.76|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|Self-pay|Self-pay|70||||70|24.5|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|70||||70|20.76|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|70||||70|20.76|70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|70||||70||70|4.82
91896160|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|70||||70||70|4.82
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|AARP [1000]|AARP [100000]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|AETNA [1015]|AETNA [101529]|82||||82|82|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|82||||82|24.31|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|82||||82|38.54|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|82||||82|41|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|82||||82|41|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|82||||82|51.66|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|82||||82|24.31|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|82||||82|45.1|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|82||||82|56.58|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|82||||82|41|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|82||||82|82|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|82||||82|24.31|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|82||||82|82|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|82||||82|24.31|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|82||||82|24.31|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|82||||82|56.58|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|82||||82|24.31|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|Self-pay|Self-pay|82||||82|28.7|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|82||||82|24.31|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|82||||82|24.31|82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|82||||82||82|24.31
91896164|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP 1ST 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|82||||82||82|24.31
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|AARP [1000]|AARP [100000]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|AETNA [1015]|AETNA [101529]|12||||12|12|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12||||12|3.56|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|12||||12|5.64|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12||||12|6|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12||||12|6|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12||||12|7.56|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12||||12|3.56|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|12||||12|6.6|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|12||||12|8.28|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12||||12|6|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12||||12|12|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12||||12|3.56|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12||||12|12|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12||||12|3.56|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|12||||12|3.56|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|12||||12|8.28|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12||||12|3.56|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|Self-pay|Self-pay|12||||12|4.2|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12||||12|3.56|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12||||12|3.56|12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12||||12||12|3.56
91896165|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ GRP EA ADDL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12||||12||12|3.56
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|AARP [1000]|AARP [100000]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|AETNA [1015]|AETNA [101529]|74||||74|74|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|74||||74|21.94|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|74||||74|34.78|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|74||||74|37|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|74||||74|37|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|74||||74|46.62|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|74||||74|21.94|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|74||||74|40.7|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|74||||74|51.06|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|74||||74|37|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|74||||74|74|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|74||||74|21.94|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|74||||74|74|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|74||||74|21.94|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|74||||74|21.94|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|74||||74|51.06|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|74||||74|21.94|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|Self-pay|Self-pay|74||||74|25.9|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|74||||74|21.94|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|74||||74|21.94|74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|74||||74||74|21.94
91896167|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM 1ST 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|74||||74||74|21.94
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|AARP [1000]|AARP [100000]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|AETNA [1015]|AETNA [101529]|69||||69|69|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|69||||69|20.46|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|69||||69|32.43|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|69||||69|34.5|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|69||||69|34.5|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|69||||69|43.47|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|69||||69|20.46|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|69||||69|37.95|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|69||||69|47.61|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|69||||69|34.5|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|69||||69|69|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|69||||69|20.46|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|69||||69|69|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|69||||69|20.46|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|69||||69|20.46|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|69||||69|47.61|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|69||||69|20.46|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|Self-pay|Self-pay|69||||69|24.15|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|69||||69|20.46|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|69||||69|20.46|69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|69||||69||69|20.46
91896168|EAP|0918 - BEHAVIORAL HEALTH TREATMENTS/SERVICES-EXTEN|HC HLTH BHV IVNTJ FAM EA ADDL 15 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|69||||69||69|20.46
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|AARP [1000]|AARP [100000]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|AETNA [1015]|AETNA [101529]|104.16||||104.16|45.93|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|104.16||||104.16|30.88|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|BCBS [1155]|BCBS UTHCT [115568]|104.16||||104.16|48.96|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|104.16||||104.16|52.08|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|104.16||||104.16|52.08|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|104.16||||104.16|65.62|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|104.16||||104.16|30.88|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|CIGNA [1260]|CIGNA GWH [126023]|104.16||||104.16|57.29|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|104.16||||104.16|71.87|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|104.16||||104.16|52.08|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|104.16||||104.16|45.93|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|104.16||||104.16|30.88|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|104.16||||104.16|45.93|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|104.16||||104.16|30.88|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|104.16||||104.16|30.88|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|104.16||||104.16|71.87|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|104.16||||104.16|30.88|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|Self-pay|Self-pay|104.16||||104.16|36.46|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|104.16||||104.16|30.88|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|104.16||||104.16|30.88|71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|104.16||||104.16||71.87|30.88
91915|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM-METHYLCELLULOSE 24 % ORAL LIQUID|600 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|104.16||||104.16||71.87|30.88
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|AARP [1000]|AARP [100000]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|AETNA [1015]|AETNA [101529]|370||||370|370|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|370||||370|109.71|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|BCBS [1155]|BCBS UTHCT [115568]|370||||370|173.9|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|370||||370|77.06|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|370||||370|185|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|370||||370|233.1|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|370||||370|109.71|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|CIGNA [1260]|CIGNA GWH [126023]|370||||370|203.5|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|GROUP PENSION ADMIN [1450]|GPA [145000]|370||||370|255.3|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|370||||370|174.44|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|370||||370|370|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|370||||370|109.71|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|370||||370|370|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|370||||370|109.71|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|370||||370|109.71|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|PHCS [1780]|PHCS MULTIPLAN [178000]|370||||370|255.3|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|370||||370|109.71|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|Self-pay|Self-pay|370||||370|129.5|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|370||||370|109.71|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|370||||370|109.71|370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|370||||370||370|77.06
92091065|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC BREATH HYDROGEN/METHANE TEST|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|370||||370||370|77.06
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|AARP [1000]|AARP [100000]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|AETNA [1015]|AETNA [101529]|150||||150|150|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|150||||150|44.48|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|BCBS [1155]|BCBS UTHCT [115568]|150||||150|70.5|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|150||||150|68.31|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|150||||150|75|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|150||||150|94.5|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|150||||150|44.48|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|CIGNA [1260]|CIGNA GWH [126023]|150||||150|82.5|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|150||||150|103.5|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|150||||150|69.58|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|150||||150|150|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|150||||150|44.48|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|150||||150|150|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|150||||150|44.48|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|150||||150|44.48|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|150||||150|103.5|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|150||||150|44.48|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|Self-pay|Self-pay|150||||150|52.5|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|150||||150|44.48|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|150||||150|44.48|150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|150||||150||150|44.48
92095249|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUC MONITOR CONT PATIENT EQUIP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|150||||150||150|44.48
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|AARP [1000]|AARP [100000]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|AETNA [1015]|AETNA [101529]|335||||335|335|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|335||||335|99.33|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|BCBS [1155]|BCBS UTHCT [115568]|335||||335|157.45|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|335||||335|138.7|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|335||||335|167.5|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|335||||335|211.05|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|335||||335|99.33|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|CIGNA [1260]|CIGNA GWH [126023]|335||||335|184.25|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|335||||335|231.15|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|335||||335|148.43|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|335||||335|335|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|335||||335|99.33|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|335||||335|335|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|335||||335|99.33|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|335||||335|99.33|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|335||||335|231.15|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|335||||335|99.33|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|Self-pay|Self-pay|335||||335|117.25|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|335||||335|99.33|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|335||||335|99.33|335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|335||||335||335|99.33
92095250|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC GLUCOSE MONITOR, CONTINUOUS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|335||||335||335|99.33
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|AARP [1000]|AARP [100000]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|AETNA [1015]|AETNA [101529]|2188||||2188|1313.78|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2188||||2188|648.74|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|BCBS [1155]|BCBS UTHCT [115568]|2188||||2188|1028.36|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2188||||2188|980.77|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2188||||2188|1094|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2188||||2188|1378.44|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2188||||2188|648.74|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|CIGNA [1260]|CIGNA GWH [126023]|2188||||2188|1203.4|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2188||||2188|1509.72|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2188||||2188|1149.78|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2188||||2188|1313.78|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2188||||2188|648.74|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2188||||2188|1313.78|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2188||||2188|648.74|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2188||||2188|648.74|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2188||||2188|1509.72|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2188||||2188|648.74|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|Self-pay|Self-pay|2188||||2188|765.8|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2188||||2188|648.74|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2188||||2188|648.74|1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2188||||2188||1509.72|648.74
92095782|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG (SLEEP STAGING)4+PARAM AGE<6|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|AARP [1000]|AARP [100000]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|AETNA [1015]|AETNA [101529]|2188||||2188|1393.56|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2188||||2188|648.74|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|BCBS [1155]|BCBS UTHCT [115568]|2188||||2188|1028.36|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2188||||2188|1042.5|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2188||||2188|1094|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2188||||2188|1378.44|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2188||||2188|648.74|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|CIGNA [1260]|CIGNA GWH [126023]|2188||||2188|1203.4|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2188||||2188|1509.72|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2188||||2188|1149.78|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2188||||2188|1393.56|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2188||||2188|648.74|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2188||||2188|1393.56|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2188||||2188|648.74|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2188||||2188|648.74|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2188||||2188|1509.72|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2188||||2188|648.74|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|Self-pay|Self-pay|2188||||2188|765.8|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2188||||2188|648.74|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2188||||2188|648.74|1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2188||||2188||1509.72|648.74
92095783|EAP|0920 - OTHER DIAGNOSTIC SERVICES-GENERAL|HC PSG <6 YRS SLEEP W/CPAP/BILVL VENT 4+PARAM|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2188||||2188||1509.72|648.74
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AARP [1000]|AARP [100000]|1858||||1858|175|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1858||||1858|210.77|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AETNA [1015]|AETNA [101529]|1858||||1858|356.86|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1858||||1858|190.45|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1858||||1858|208.68|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1858||||1858|208.68|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|1858||||1858|873.26|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1858||||1858|144.05|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1858||||1858|929|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1858||||1858|1170.54|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1858||||1858|190.45|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1858||||1858|208.68|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|1858||||1858|1021.9|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1858||||1858|1282.02|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1858||||1858|287.66|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1858||||1858|223.5|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1858||||1858|356.86|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1858||||1858|190.45|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1858||||1858|208.68|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1858||||1858|356.86|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1858||||1858|190.45|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1858||||1858|190.45|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1858||||1858|1282.02|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1858||||1858|190.45|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|Self-pay|Self-pay|1858||||1858|650.3|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1858||||1858|190.45|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1858||||1858|190.45|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1858||||1858|175|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1858||||1858|208.68|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1858||||1858|208.68|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1858||||1858|175|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1858||||1858|208.68|1282.02|144.05
92193880|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC US DUPLEX EXTRACRAN/CAROTID BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1858||||1858|417.37|1282.02|144.05
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AARP [1000]|AARP [100000]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AETNA [1015]|AETNA [101529]|316||||316|229.22|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|316||||316|112.51|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS [1155]|BCBS UTHCT [115568]|316||||316|148.52|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|316||||316|131.36|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|316||||316|158|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|316||||316|199.08|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|316||||316|112.51|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|CIGNA [1260]|CIGNA GWH [126023]|316||||316|173.8|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|316||||316|218.04|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|316||||316|136.21|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|316||||316|229.22|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|316||||316|112.51|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|316||||316|229.22|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|316||||316|112.51|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|316||||316|112.51|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|316||||316|218.04|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|316||||316|112.51|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|Self-pay|Self-pay|316||||316|110.6|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|316||||316|112.51|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|316||||316|112.51|229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|316||||316||229.22|110.6
92193882|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC EXTRACRANIAL DUPLEX SCAN UNIL/LIMIT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|316||||316||229.22|110.6
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|AARP [1000]|AARP [100000]|426||||426|175|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|426||||426|102.53|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|AETNA [1015]|AETNA [101529]|426||||426|151.73|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|426||||426|126.31|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|426||||426|101.52|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|426||||426|101.52|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|426||||426|200.22|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|426||||426|128.15|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|426||||426|213|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|426||||426|268.38|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|426||||426|126.31|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|426||||426|101.52|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|426||||426|234.3|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|426||||426|293.94|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|426||||426|139.94|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|426||||426|108.73|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|426||||426|151.73|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|426||||426|126.31|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|426||||426|101.52|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|426||||426|151.73|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|426||||426|126.31|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|426||||426|126.31|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|426||||426|293.94|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|426||||426|126.31|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|Self-pay|Self-pay|426||||426|149.1|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|426||||426|126.31|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|426||||426|126.31|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|426||||426|175|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|426||||426|101.52|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|426||||426|101.52|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|426||||426|175|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|426||||426|101.52|293.94|101.52
92193922|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 1-2 LEVEL BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|426||||426|203.04|293.94|101.52
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AARP [1000]|AARP [100000]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AETNA [1015]|AETNA [101529]|622||||622|236.26|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|622||||622|126.3|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|622||||622|292.34|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|622||||622|142.74|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|622||||622|311|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|622||||622|391.86|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|622||||622|126.3|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|622||||622|342.1|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|622||||622|429.18|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|622||||622|174.44|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|622||||622|236.26|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|622||||622|126.3|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|622||||622|236.26|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|622||||622|126.3|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|622||||622|126.3|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|622||||622|429.18|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|622||||622|126.3|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|Self-pay|Self-pay|622||||622|217.7|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|622||||622|126.3|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|622||||622|126.3|429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|622||||622||429.18|126.3
92193923|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DOPPLER ART 3+ LEVEL BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|622||||622||429.18|126.3
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|AARP [1000]|AARP [100000]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|AETNA [1015]|AETNA [101529]|578||||578|292.22|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|578||||578|135.95|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|578||||578|271.66|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|578||||578|181.27|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|578||||578|289|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|578||||578|364.14|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|578||||578|135.95|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|578||||578|317.9|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|578||||578|398.82|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|578||||578|330.56|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|578||||578|292.22|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|578||||578|135.95|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|578||||578|292.22|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|578||||578|135.95|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|578||||578|135.95|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|578||||578|398.82|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|578||||578|135.95|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|Self-pay|Self-pay|578||||578|202.3|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|578||||578|135.95|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|578||||578|135.95|398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|578||||578||398.82|135.95
92193924|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC LOWER EXTREM STUDY STRESS BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|578||||578||398.82|135.95
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|AARP [1000]|AARP [100000]|2676||||2676|175|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2676||||2676|210.77|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|AETNA [1015]|AETNA [101529]|2676||||2676|453.94|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2676||||2676|230.56|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2676||||2676|208.68|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2676||||2676|208.68|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|2676||||2676|1257.72|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2676||||2676|276.72|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2676||||2676|1338|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2676||||2676|1685.88|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2676||||2676|230.56|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2676||||2676|208.68|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|2676||||2676|1471.8|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2676||||2676|1846.44|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2676||||2676|287.66|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2676||||2676|223.5|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2676||||2676|453.94|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2676||||2676|230.56|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2676||||2676|208.68|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2676||||2676|453.94|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2676||||2676|230.56|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2676||||2676|230.56|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2676||||2676|1846.44|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2676||||2676|230.56|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|Self-pay|Self-pay|2676||||2676|936.6|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2676||||2676|230.56|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2676||||2676|230.56|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2676||||2676|175|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2676||||2676|208.68|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2676||||2676|208.68|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2676||||2676|175|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2676||||2676|208.68|1846.44|175
92193925|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2676||||2676|417.37|1846.44|175
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|AARP [1000]|AARP [100000]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|AETNA [1015]|AETNA [101529]|1676||||1676|240.07|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1676||||1676|112.51|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|BCBS [1155]|BCBS UTHCT [115568]|1676||||1676|787.72|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1676||||1676|144.48|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1676||||1676|838|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1676||||1676|1055.88|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1676||||1676|112.51|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|CIGNA [1260]|CIGNA GWH [126023]|1676||||1676|921.8|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1676||||1676|1156.44|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1676||||1676|136.21|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1676||||1676|240.07|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1676||||1676|112.51|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1676||||1676|240.07|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1676||||1676|112.51|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1676||||1676|112.51|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1676||||1676|1156.44|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1676||||1676|112.51|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|Self-pay|Self-pay|1676||||1676|586.6|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1676||||1676|112.51|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1676||||1676|112.51|1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1676||||1676||1156.44|112.51
92193926|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL LOW EXTREM UNILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1676||||1676||1156.44|112.51
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AARP [1000]|AARP [100000]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AETNA [1015]|AETNA [101529]|1826||||1826|368.26|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1826||||1826|194.46|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|1826||||1826|858.22|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1826||||1826|144.05|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1826||||1826|913|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1826||||1826|1150.38|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1826||||1826|194.46|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|1826||||1826|1004.3|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1826||||1826|1259.94|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1826||||1826|287.66|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1826||||1826|368.26|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1826||||1826|194.46|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1826||||1826|368.26|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1826||||1826|194.46|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1826||||1826|194.46|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1826||||1826|1259.94|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1826||||1826|194.46|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|Self-pay|Self-pay|1826||||1826|639.1|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1826||||1826|194.46|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1826||||1826|194.46|1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1826||||1826||1259.94|144.05
92193930|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ARTERIAL UPPER EXT COMPLETE BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1826||||1826||1259.94|144.05
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AARP [1000]|AARP [100000]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AETNA [1015]|AETNA [101529]|458||||458|229.9|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|458||||458|112.51|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS [1155]|BCBS UTHCT [115568]|458||||458|215.26|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|458||||458|131.78|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|458||||458|229|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|458||||458|288.54|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|458||||458|112.51|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|CIGNA [1260]|CIGNA GWH [126023]|458||||458|251.9|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|458||||458|316.02|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|458||||458|136.21|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|458||||458|229.9|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|458||||458|112.51|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|458||||458|229.9|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|458||||458|112.51|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|458||||458|112.51|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|458||||458|316.02|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|458||||458|112.51|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|Self-pay|Self-pay|458||||458|160.3|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|458||||458|112.51|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|458||||458|112.51|316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|458||||458||316.02|112.51
92193931|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX UPPR EXTREM ARTERIAL UNILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|458||||458||316.02|112.51
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AARP [1000]|AARP [100000]|2700||||2700|175|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2700||||2700|210.77|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AETNA [1015]|AETNA [101529]|2700||||2700|348.6|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2700||||2700|184.44|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2700||||2700|208.68|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2700||||2700|208.68|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS [1155]|BCBS UTHCT [115568]|2700||||2700|1269|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2700||||2700|202.72|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2700||||2700|1350|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2700||||2700|1701|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2700||||2700|184.44|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2700||||2700|208.68|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|CIGNA [1260]|CIGNA GWH [126023]|2700||||2700|1485|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|2700||||2700|1863|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2700||||2700|287.66|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2700||||2700|223.5|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2700||||2700|348.6|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2700||||2700|184.44|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2700||||2700|208.68|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2700||||2700|348.6|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2700||||2700|184.44|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|2700||||2700|184.44|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|2700||||2700|1863|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2700||||2700|184.44|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|Self-pay|Self-pay|2700||||2700|945|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2700||||2700|184.44|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2700||||2700|184.44|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2700||||2700|175|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2700||||2700|208.68|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2700||||2700|208.68|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2700||||2700|175|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2700||||2700|208.68|1863|175
92193970|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY BILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2700||||2700|417.37|1863|175
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AARP [1000]|AARP [100000]|1854||||1854|175|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1854||||1854|99.8|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AETNA [1015]|AETNA [101529]|1854||||1854|217.85|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1854||||1854|112.51|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1854||||1854|98.82|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1854||||1854|98.82|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS [1155]|BCBS UTHCT [115568]|1854||||1854|871.38|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1854||||1854|122.6|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1854||||1854|927|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1854||||1854|1168.02|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1854||||1854|112.51|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1854||||1854|98.82|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|CIGNA [1260]|CIGNA GWH [126023]|1854||||1854|1019.7|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1854||||1854|1279.26|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1854||||1854|136.21|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1854||||1854|105.83|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1854||||1854|217.85|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1854||||1854|112.51|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1854||||1854|98.82|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1854||||1854|217.85|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1854||||1854|112.51|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1854||||1854|112.51|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1854||||1854|1279.26|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1854||||1854|112.51|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|Self-pay|Self-pay|1854||||1854|648.9|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1854||||1854|112.51|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1854||||1854|112.51|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1854||||1854|175|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1854||||1854|98.82|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1854||||1854|98.82|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1854||||1854|175|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1854||||1854|98.82|1279.26|98.82
92193971|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX VENOUS EXTREMITY UNILAT|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1854||||1854|197.63|1279.26|98.82
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|AARP [1000]|AARP [100000]|699||||699|175|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|699||||699|210.77|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|AETNA [1015]|AETNA [101529]|699||||699|495.22|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|699||||699|230.56|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|699||||699|208.68|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|699||||699|208.68|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|699||||699|328.53|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|699||||699|281.53|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|699||||699|349.5|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|699||||699|440.37|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|699||||699|230.56|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|699||||699|208.68|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|699||||699|384.45|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|699||||699|482.31|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|699||||699|287.66|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|699||||699|223.5|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|699||||699|495.22|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|699||||699|230.56|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|699||||699|208.68|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|699||||699|495.22|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|699||||699|230.56|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|699||||699|230.56|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|699||||699|482.31|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|699||||699|230.56|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|Self-pay|Self-pay|699||||699|244.65|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|699||||699|230.56|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|699||||699|230.56|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|699||||699|175|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|699||||699|208.68|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|699||||699|208.68|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|699||||699|175|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|699||||699|208.68|495.22|175
92193975|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ART/VEIN ABD/PEL/SCROT/RETRO COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|699||||699|417.37|495.22|175
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|AARP [1000]|AARP [100000]|1653||||1653|175|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1653||||1653|99.8|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|AETNA [1015]|AETNA [101529]|1653||||1653|268.03|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1653||||1653|112.51|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1653||||1653|98.82|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1653||||1653|98.82|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|BCBS [1155]|BCBS UTHCT [115568]|1653||||1653|776.91|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1653||||1653|144.48|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1653||||1653|826.5|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1653||||1653|1041.39|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1653||||1653|112.51|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1653||||1653|98.82|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|CIGNA [1260]|CIGNA GWH [126023]|1653||||1653|909.15|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1653||||1653|1140.57|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1653||||1653|136.21|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1653||||1653|105.83|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1653||||1653|268.03|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1653||||1653|112.51|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1653||||1653|98.82|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1653||||1653|268.03|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1653||||1653|112.51|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1653||||1653|112.51|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1653||||1653|1140.57|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1653||||1653|112.51|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|Self-pay|Self-pay|1653||||1653|578.55|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1653||||1653|112.51|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1653||||1653|112.51|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1653||||1653|175|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1653||||1653|98.82|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1653||||1653|98.82|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1653||||1653|175|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1653||||1653|98.82|1140.57|98.82
92193976|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX ABD/PEL/RETRO LIMITED|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1653||||1653|197.63|1140.57|98.82
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|AARP [1000]|AARP [100000]|1500||||1500|175|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1500||||1500|210.77|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|AETNA [1015]|AETNA [101529]|1500||||1500|335.81|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1500||||1500|178.43|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1500||||1500|208.68|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1500||||1500|208.68|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|BCBS [1155]|BCBS UTHCT [115568]|1500||||1500|705|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1500||||1500|144.48|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1500||||1500|750|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1500||||1500|945|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1500||||1500|178.43|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1500||||1500|208.68|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|CIGNA [1260]|CIGNA GWH [126023]|1500||||1500|825|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1500||||1500|1035|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1500||||1500|287.66|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1500||||1500|223.5|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1500||||1500|335.81|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1500||||1500|178.43|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1500||||1500|208.68|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1500||||1500|335.81|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1500||||1500|178.43|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1500||||1500|178.43|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1500||||1500|1035|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1500||||1500|178.43|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|Self-pay|Self-pay|1500||||1500|525|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1500||||1500|178.43|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1500||||1500|178.43|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1500||||1500|175|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1500||||1500|208.68|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1500||||1500|208.68|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1500||||1500|175|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1500||||1500|208.68|1035|144.48
92193978|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/GRAFT COMPLETE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1500||||1500|417.37|1035|144.48
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|AARP [1000]|AARP [100000]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|AETNA [1015]|AETNA [101529]|1436||||1436|215.66|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1436||||1436|112.51|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|BCBS [1155]|BCBS UTHCT [115568]|1436||||1436|674.92|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1436||||1436|139.64|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1436||||1436|718|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1436||||1436|904.68|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1436||||1436|112.51|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|CIGNA [1260]|CIGNA GWH [126023]|1436||||1436|789.8|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|GROUP PENSION ADMIN [1450]|GPA [145000]|1436||||1436|990.84|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1436||||1436|136.21|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1436||||1436|215.66|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1436||||1436|112.51|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1436||||1436|215.66|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1436||||1436|112.51|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|1436||||1436|112.51|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|PHCS [1780]|PHCS MULTIPLAN [178000]|1436||||1436|990.84|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1436||||1436|112.51|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|Self-pay|Self-pay|1436||||1436|502.6|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1436||||1436|112.51|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1436||||1436|112.51|990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1436||||1436||990.84|112.51
92193979|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX AORTA/IVC/ILIAC/GRAFT LTD|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1436||||1436||990.84|112.51
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|AARP [1000]|AARP [100000]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|AETNA [1015]|AETNA [101529]|671||||671|131.57|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|671||||671|71.84|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|BCBS [1155]|BCBS UTHCT [115568]|671||||671|315.37|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|671||||671|68.75|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|671||||671|335.5|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|671||||671|422.73|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|671||||671|71.84|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|CIGNA [1260]|CIGNA GWH [126023]|671||||671|369.05|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|GROUP PENSION ADMIN [1450]|GPA [145000]|671||||671|462.99|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|671||||671|136.21|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|671||||671|131.57|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|671||||671|71.84|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|671||||671|131.57|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|671||||671|71.84|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|671||||671|71.84|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|PHCS [1780]|PHCS MULTIPLAN [178000]|671||||671|462.99|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|671||||671|71.84|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|Self-pay|Self-pay|671||||671|234.85|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|671||||671|71.84|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|671||||671|71.84|462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|671||||671||462.99|68.75
92193981|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX PENILE LIMITED/FOLLOWUP|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|671||||671||462.99|68.75
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|AARP [1000]|AARP [100000]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|AETNA [1015]|AETNA [101529]|299||||299|240.43|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|299||||299|112.51|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|BCBS [1155]|BCBS UTHCT [115568]|299||||299|140.53|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|299||||299|139.64|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|299||||299|149.5|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|299||||299|188.37|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|299||||299|112.51|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|CIGNA [1260]|CIGNA GWH [126023]|299||||299|164.45|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|299||||299|206.31|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|299||||299|136.21|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|299||||299|240.43|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|299||||299|112.51|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|299||||299|240.43|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|299||||299|112.51|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|299||||299|112.51|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|299||||299|206.31|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|299||||299|112.51|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|Self-pay|Self-pay|299||||299|104.65|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|299||||299|112.51|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|299||||299|112.51|240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|299||||299||240.43|104.65
92193990|EAP|0921 - OTHER DIAGNOSTIC SERVICES-PERIPHERAL VASCUL|HC DUPLEX OF HEMODIALYSIS ACCESS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|299||||299||240.43|104.65
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|AARP [1000]|AARP [100000]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|AETNA [1015]|AETNA [101529]|81||||81|81|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|81||||81|24.02|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|BCBS [1155]|BCBS UTHCT [115568]|81||||81|38.07|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|81||||81|81|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|81||||81|40.5|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|81||||81|51.03|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|81||||81|24.02|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|CIGNA [1260]|CIGNA GWH [126023]|81||||81|44.55|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|GROUP PENSION ADMIN [1450]|GPA [145000]|81||||81|55.89|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|81||||81|1149.78|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|81||||81|81|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|81||||81|24.02|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|81||||81|81|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|81||||81|24.02|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|81||||81|24.02|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|PHCS [1780]|PHCS MULTIPLAN [178000]|81||||81|55.89|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|81||||81|24.02|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|Self-pay|Self-pay|81||||81|28.35|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|81||||81|24.02|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|81||||81|24.02|1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|81||||81||1149.78|24.02
92495004|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|81||||81||1149.78|24.02
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|AARP [1000]|AARP [100000]|124||||124|124|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|124||||124|446.75|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|AETNA [1015]|AETNA [101529]|124||||124|124|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|124||||124|36.77|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|124||||124|442.33|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|124||||124|442.33|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|BCBS [1155]|BCBS UTHCT [115568]|124||||124|58.28|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|124||||124|38.53|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|124||||124|62|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|124||||124|78.12|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|124||||124|36.77|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|124||||124|442.33|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|CIGNA [1260]|CIGNA GWH [126023]|124||||124|68.2|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|GROUP PENSION ADMIN [1450]|GPA [145000]|124||||124|85.56|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|124||||124|609.73|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|124||||124|473.74|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|124||||124|124|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|124||||124|36.77|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|124||||124|442.33|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|124||||124|124|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|124||||124|36.77|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|124||||124|36.77|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|PHCS [1780]|PHCS MULTIPLAN [178000]|124||||124|85.56|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|124||||124|36.77|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|Self-pay|Self-pay|124||||124|43.4|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|124||||124|36.77|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|124||||124|36.77|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|124||||124|124|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|124||||124|442.33|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|124||||124|442.33|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|124||||124|124|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|124||||124|442.33|884.66|36.77
92495070|EAP|0924 - OTHER DIAGNOSTIC SERVICES-ALLERGY TEST|HC BRONCHIAL CHALLENGE|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|124||||124|884.66|884.66|36.77
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|186||||186|74.5|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|186||||186|55.15|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|186||||186|87.42|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|186||||186|0|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|186||||186|93|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|186||||186|117.18|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|186||||186|55.15|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|186||||186|102.3|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|186||||186|128.34|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|186||||186|21.45|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|186||||186|74.5|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|186||||186|55.15|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|186||||186|74.5|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|186||||186|55.15|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|186||||186|55.15|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|186||||186|128.34|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|186||||186|55.15|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|186||||186|65.1|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|186||||186|55.15|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|186||||186|55.15|128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|186||||186||128.34|21.45
9259|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BENZTROPINE 1 MG/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|186||||186||128.34|21.45
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.2||||0.2|0.09|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.2||||0.2|0.06|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.2||||0.2|0.09|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.2||||0.2|0.1|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.2||||0.2|0.1|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.2||||0.2|0.13|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.2||||0.2|0.06|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.2||||0.2|0.11|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.2||||0.2|0.14|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.2||||0.2|0.1|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.2||||0.2|0.09|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.2||||0.2|0.06|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.2||||0.2|0.09|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.2||||0.2|0.06|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.2||||0.2|0.06|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.2||||0.2|0.14|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.2||||0.2|0.06|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|0.2||||0.2|0.07|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.2||||0.2|0.06|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.2||||0.2|0.06|0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.2||||0.2||0.14|0.06
9285|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BISMUTH SUBSALICYLATE 262 MG CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.2||||0.2||0.14|0.06
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|AARP [1000]|AARP [100000]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|AETNA [1015]|AETNA [101529]|22.32||||22.32|9.84|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|22.32||||22.32|6.62|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|BCBS [1155]|BCBS UTHCT [115568]|22.32||||22.32|10.49|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|22.32||||22.32|11.16|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|22.32||||22.32|11.16|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|22.32||||22.32|14.06|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|22.32||||22.32|6.62|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|CIGNA [1260]|CIGNA GWH [126023]|22.32||||22.32|12.28|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|22.32||||22.32|15.4|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|22.32||||22.32|11.16|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|22.32||||22.32|9.84|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|22.32||||22.32|6.62|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|22.32||||22.32|9.84|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|22.32||||22.32|6.62|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|22.32||||22.32|6.62|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|22.32||||22.32|15.4|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|22.32||||22.32|6.62|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|Self-pay|Self-pay|22.32||||22.32|7.81|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|22.32||||22.32|6.62|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|22.32||||22.32|6.62|15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|22.32||||22.32||15.4|6.62
93052|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|BARIUM SULFATE 0.1 % (W/V), 0.1 % (W/W) ORAL SUSPENSION|450 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|22.32||||22.32||15.4|6.62
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|AARP [1000]|AARP [100000]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|9.24||||9.24|4.07|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.24||||9.24|2.74|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|9.24||||9.24|4.34|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.24||||9.24|4.62|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.24||||9.24|4.62|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.24||||9.24|5.82|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.24||||9.24|2.74|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|9.24||||9.24|5.08|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.24||||9.24|6.38|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.24||||9.24|4.62|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.24||||9.24|4.07|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.24||||9.24|2.74|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.24||||9.24|4.07|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.24||||9.24|2.74|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.24||||9.24|2.74|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.24||||9.24|6.38|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.24||||9.24|2.74|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|Self-pay|Self-pay|9.24||||9.24|3.23|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.24||||9.24|2.74|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.24||||9.24|2.74|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.24||||9.24||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AARP [1000]|AARP [100000]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AETNA [1015]|AETNA [101529]|8.52||||8.52|3.76|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.52||||8.52|2.53|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BCBS UTHCT [115568]|8.52||||8.52|4|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.52||||8.52|4.26|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.52||||8.52|4.26|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.52||||8.52|5.37|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.52||||8.52|2.53|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|CIGNA [1260]|CIGNA GWH [126023]|8.52||||8.52|4.69|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|8.52||||8.52|5.88|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.52||||8.52|4.26|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.52||||8.52|3.76|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.52||||8.52|2.53|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.52||||8.52|3.76|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.52||||8.52|2.53|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.52||||8.52|2.53|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|8.52||||8.52|5.88|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.52||||8.52|2.53|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|Self-pay|Self-pay|8.52||||8.52|2.98|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.52||||8.52|2.53|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.52||||8.52|2.53|6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.52||||8.52||6.38|2.53
9308|ERX|0250 - PHARMACY-GENERAL|BUMETANIDE 0.25 MG/ML INJECTION SOLUTION|4 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.52||||8.52||6.38|2.53
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AARP [1000]|AARP [100000]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|6.21||||6.21|4.56|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AETNA [1015]|AETNA [101529]|6.21||||6.21|4.56|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BCBS UTHCT [115568]|6.21||||6.21|2.92|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BCBS UTHCT [115568]|6.21||||6.21|2.92|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.21||||6.21|0|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.21||||6.21|0|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.21||||6.21|3.11|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.21||||6.21|3.11|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.21||||6.21|3.91|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.21||||6.21|3.91|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA GWH [126023]|6.21||||6.21|3.42|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|CIGNA [1260]|CIGNA GWH [126023]|6.21||||6.21|3.42|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.21||||6.21|4.28|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6.21||||6.21|4.28|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.21||||6.21|3.11|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.21||||6.21|3.11|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.21||||6.21|4.56|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.21||||6.21|4.56|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.21||||6.21|4.56|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.21||||6.21|4.56|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.21||||6.21|4.28|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6.21||||6.21|4.28|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|Self-pay|Self-pay|6.21||||6.21|2.17|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|Self-pay|Self-pay|6.21||||6.21|2.17|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.21||||6.21|1.84|4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.21||||6.21||4.56|1.84
93084|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.21||||6.21||4.56|1.84
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.06||||1.06|0.47|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.06||||1.06|0.31|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.06||||1.06|0.5|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.06||||1.06|0.53|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.06||||1.06|0.53|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.06||||1.06|0.67|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.06||||1.06|0.31|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.06||||1.06|0.58|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.06||||1.06|0.73|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.06||||1.06|0.53|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.06||||1.06|0.47|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.06||||1.06|0.31|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.06||||1.06|0.47|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.06||||1.06|0.31|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.06||||1.06|0.31|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.06||||1.06|0.73|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.06||||1.06|0.31|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.06||||1.06|0.37|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.06||||1.06|0.31|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.06||||1.06|0.31|0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.06||||1.06||0.73|0.31
9309|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.06||||1.06||0.73|0.31
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.71||||2.71|1.2|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.71||||2.71|0.8|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.71||||2.71|1.27|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.71||||2.71|1.36|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.71||||2.71|1.36|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.71||||2.71|1.71|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.71||||2.71|0.8|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.71||||2.71|1.49|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.71||||2.71|1.87|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.71||||2.71|1.36|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.71||||2.71|1.2|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.71||||2.71|0.8|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.71||||2.71|1.2|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.71||||2.71|0.8|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.71||||2.71|0.8|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.71||||2.71|1.87|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.71||||2.71|0.8|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|Self-pay|Self-pay|2.71||||2.71|0.95|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.71||||2.71|0.8|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.71||||2.71|0.8|1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.71||||2.71||1.87|0.8
9310|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUMETANIDE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.71||||2.71||1.87|0.8
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|AARP [1000]|AARP [100000]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|AETNA [1015]|AETNA [101529]|41.7||||41.7|18.39|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|41.7||||41.7|12.36|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|BCBS [1155]|BCBS UTHCT [115568]|41.7||||41.7|19.6|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|41.7||||41.7|20.85|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|41.7||||41.7|20.85|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|41.7||||41.7|26.27|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|41.7||||41.7|12.36|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|CIGNA [1260]|CIGNA GWH [126023]|41.7||||41.7|22.94|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|41.7||||41.7|28.77|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|41.7||||41.7|20.85|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|41.7||||41.7|18.39|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|41.7||||41.7|12.36|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|41.7||||41.7|18.39|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|41.7||||41.7|12.36|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|41.7||||41.7|12.36|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|41.7||||41.7|28.77|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|41.7||||41.7|12.36|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|Self-pay|Self-pay|41.7||||41.7|14.59|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|41.7||||41.7|12.36|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|41.7||||41.7|12.36|28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|41.7||||41.7||28.77|12.36
9317|ERX|0250 - PHARMACY-GENERAL|BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|41.7||||41.7||28.77|12.36
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.81||||3.81|1.68|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.81||||3.81|1.13|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.81||||3.81|1.79|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.81||||3.81|1.91|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.81||||3.81|1.91|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.81||||3.81|2.4|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.81||||3.81|1.13|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.81||||3.81|2.1|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.81||||3.81|2.63|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.81||||3.81|1.91|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.81||||3.81|1.68|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.81||||3.81|1.13|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.81||||3.81|1.68|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.81||||3.81|1.13|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.81||||3.81|1.13|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.81||||3.81|2.63|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.81||||3.81|1.13|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|Self-pay|Self-pay|3.81||||3.81|1.33|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.81||||3.81|1.13|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.81||||3.81|1.13|2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.81||||3.81||2.63|1.13
9322|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUPROPION HCL 75 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.81||||3.81||2.63|1.13
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.14||||0.14|0.06|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.14||||0.14|0.04|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.14||||0.14|0.07|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.14||||0.14|0.07|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.14||||0.14|0.07|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.14||||0.14|0.09|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.14||||0.14|0.04|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.14||||0.14|0.08|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.14||||0.14|0.1|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.14||||0.14|0.07|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.14||||0.14|0.06|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.14||||0.14|0.04|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.14||||0.14|0.06|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.14||||0.14|0.04|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.14||||0.14|0.04|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.14||||0.14|0.1|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.14||||0.14|0.04|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.14||||0.14|0.05|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.14||||0.14|0.04|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.14||||0.14|0.04|0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.14||||0.14||0.1|0.04
9323|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.14||||0.14||0.1|0.04
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.1||||0.1|0.04|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.1||||0.1|0.03|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.1||||0.1|0.05|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.1||||0.1|0.05|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.1||||0.1|0.05|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.1||||0.1|0.06|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.1||||0.1|0.03|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.1||||0.1|0.06|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.1||||0.1|0.07|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.1||||0.1|0.05|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.1||||0.1|0.04|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.1||||0.1|0.03|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.1||||0.1|0.04|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.1||||0.1|0.03|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.1||||0.1|0.03|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.1||||0.1|0.07|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.1||||0.1|0.03|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|Self-pay|Self-pay|0.1||||0.1|0.03|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.1||||0.1|0.03|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.1||||0.1|0.03|0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.1||||0.1||0.07|0.03
9324|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BUSPIRONE 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.1||||0.1||0.07|0.03
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|16.64||||16.64|13.97|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|16.64||||16.64|4.93|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|16.64||||16.64|7.82|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|16.64||||16.64|0|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|16.64||||16.64|8.32|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|16.64||||16.64|10.48|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|16.64||||16.64|4.93|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|16.64||||16.64|9.15|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|16.64||||16.64|11.48|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|16.64||||16.64|3.7|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|16.64||||16.64|13.97|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|16.64||||16.64|4.93|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|16.64||||16.64|13.97|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|16.64||||16.64|4.93|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|16.64||||16.64|4.93|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|16.64||||16.64|11.48|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|16.64||||16.64|4.93|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|16.64||||16.64|5.82|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|16.64||||16.64|4.93|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|16.64||||16.64|4.93|13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|16.64||||16.64||13.97|3.7
9334|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|BUTORPHANOL 2 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|16.64||||16.64||13.97|3.7
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AARP [1000]|AARP [100000]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AETNA [1015]|AETNA [101529]|9709.51||||9709.51|4281.89|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9709.51||||9709.51|2878.87|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BCBS UTHCT [115568]|9709.51||||9709.51|4563.47|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9709.51||||9709.51|0|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9709.51||||9709.51|4854.76|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9709.51||||9709.51|6116.99|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9709.51||||9709.51|2878.87|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|CIGNA [1260]|CIGNA GWH [126023]|9709.51||||9709.51|4854.76|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9709.51||||9709.51|6699.56|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9709.51||||9709.51|3538.19|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9709.51||||9709.51|4281.89|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9709.51||||9709.51|2878.87|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9709.51||||9709.51|4281.89|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9709.51||||9709.51|2878.87|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9709.51||||9709.51|2878.87|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9709.51||||9709.51|6699.56|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9709.51||||9709.51|2878.87|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|Self-pay|Self-pay|9709.51||||9709.51|3398.33|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9709.51||||9709.51|2878.87|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9709.51||||9709.51|2878.87|6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9709.51||||9709.51||6699.56|2878.87
9347|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION|2 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9709.51||||9709.51||6699.56|2878.87
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.99||||1.99|0.88|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.99||||1.99|0.59|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.99||||1.99|0.94|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.99||||1.99|1|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.99||||1.99|1|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.99||||1.99|1.25|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.99||||1.99|0.59|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.99||||1.99|1.09|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.99||||1.99|1.37|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.99||||1.99|1|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.99||||1.99|0.88|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.99||||1.99|0.59|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.99||||1.99|0.88|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.99||||1.99|0.59|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.99||||1.99|0.59|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.99||||1.99|1.37|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.99||||1.99|0.59|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|Self-pay|Self-pay|1.99||||1.99|0.7|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.99||||1.99|0.59|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.99||||1.99|0.59|1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.99||||1.99||1.37|0.59
9350|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCITRIOL 0.25 MCG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.99||||1.99||1.37|0.59
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|6400.51||||6400.51|3200.26|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6400.51||||6400.51|2107.52|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|6400.51||||6400.51|4658.4|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6400.51||||6400.51|1897.75|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6400.51||||6400.51|2086.65|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6400.51||||6400.51|2086.65|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|6400.51||||6400.51|3008.24|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6400.51||||6400.51|0|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6400.51||||6400.51|3200.26|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6400.51||||6400.51|4032.32|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6400.51||||6400.51|1897.75|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6400.51||||6400.51|2086.65|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|6400.51||||6400.51|3200.26|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6400.51||||6400.51|4416.35|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6400.51||||6400.51|98.89|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6400.51||||6400.51|2086.65|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6400.51||||6400.51|4658.4|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6400.51||||6400.51|1897.75|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6400.51||||6400.51|2086.65|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6400.51||||6400.51|4658.4|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6400.51||||6400.51|1897.75|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6400.51||||6400.51|1897.75|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6400.51||||6400.51|4416.35|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6400.51||||6400.51|1897.75|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|Self-pay|Self-pay|6400.51||||6400.51|2240.18|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6400.51||||6400.51|1897.75|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6400.51||||6400.51|1897.75|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6400.51||||6400.51|3200.26|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6400.51||||6400.51|2086.65|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6400.51||||6400.51|2086.65|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6400.51||||6400.51|3200.26|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6400.51||||6400.51|2086.65|4658.4|98.89
93566|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 250 MCG SUBCUTANEOUS SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6400.51||||6400.51|4173.3|4658.4|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|12801.02||||12801.02|6400.51|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12801.02||||12801.02|4215.03|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|12801.02||||12801.02|9316.8|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12801.02||||12801.02|3795.5|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12801.02||||12801.02|4173.3|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12801.02||||12801.02|4173.3|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|12801.02||||12801.02|6016.48|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12801.02||||12801.02|0|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12801.02||||12801.02|6400.51|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12801.02||||12801.02|8064.64|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12801.02||||12801.02|3795.5|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12801.02||||12801.02|4173.3|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|12801.02||||12801.02|6400.51|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|12801.02||||12801.02|8832.7|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12801.02||||12801.02|98.89|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12801.02||||12801.02|4173.3|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12801.02||||12801.02|9316.8|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12801.02||||12801.02|3795.5|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12801.02||||12801.02|4173.3|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12801.02||||12801.02|9316.8|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12801.02||||12801.02|3795.5|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|12801.02||||12801.02|3795.5|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|12801.02||||12801.02|8832.7|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12801.02||||12801.02|3795.5|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|Self-pay|Self-pay|12801.02||||12801.02|4480.36|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12801.02||||12801.02|3795.5|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12801.02||||12801.02|3795.5|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12801.02||||12801.02|6400.51|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12801.02||||12801.02|4173.3|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12801.02||||12801.02|4173.3|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12801.02||||12801.02|6400.51|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12801.02||||12801.02|4173.3|9316.8|98.89
93567|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ROMIPLOSTIM 500 MCG SUBCUTANEOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12801.02||||12801.02|8346.6|9316.8|98.89
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|440.08||||440.08|0|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|440.08||||440.08|130.48|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|440.08||||440.08|206.84|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|440.08||||440.08|0|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|440.08||||440.08|220.04|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|440.08||||440.08|277.25|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|440.08||||440.08|130.48|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|440.08||||440.08|242.04|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|440.08||||440.08|303.66|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|440.08||||440.08|18.43|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|440.08||||440.08|0|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|440.08||||440.08|130.48|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|440.08||||440.08|0|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|440.08||||440.08|130.48|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|440.08||||440.08|130.48|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|440.08||||440.08|303.66|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|440.08||||440.08|130.48|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|440.08||||440.08|154.03|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|440.08||||440.08|130.48|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|440.08||||440.08|130.48|303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|440.08||||440.08||303.66|18.43
93574|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|440.08||||440.08||303.66|18.43
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|AARP [1000]|AARP [100000]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|AETNA [1015]|AETNA [101529]|1057.65||||1057.65|428.4|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1057.65||||1057.65|313.59|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS [1155]|BCBS UTHCT [115568]|1057.65||||1057.65|497.1|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1057.65||||1057.65|0|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1057.65||||1057.65|528.83|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1057.65||||1057.65|666.32|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1057.65||||1057.65|313.59|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|CIGNA [1260]|CIGNA GWH [126023]|1057.65||||1057.65|528.83|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1057.65||||1057.65|729.78|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1057.65||||1057.65|30.18|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1057.65||||1057.65|428.4|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1057.65||||1057.65|313.59|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1057.65||||1057.65|428.4|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1057.65||||1057.65|313.59|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1057.65||||1057.65|313.59|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1057.65||||1057.65|729.78|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1057.65||||1057.65|313.59|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|Self-pay|Self-pay|1057.65||||1057.65|370.18|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1057.65||||1057.65|313.59|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1057.65||||1057.65|313.59|729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1057.65||||1057.65||729.78|30.18
93747|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|MITOXANTRONE 2 MG/ML CONCENTRATE,INTRAVENOUS|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1057.65||||1057.65||729.78|30.18
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AARP [1000]|AARP [100000]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.18||||0.18|0.08|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.18||||0.18|0.05|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.18||||0.18|0.08|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.18||||0.18|0.09|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.18||||0.18|0.09|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.18||||0.18|0.11|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.18||||0.18|0.05|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.18||||0.18|0.1|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.18||||0.18|0.12|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.18||||0.18|0.09|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.18||||0.18|0.08|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.18||||0.18|0.05|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.18||||0.18|0.08|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.18||||0.18|0.05|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.18||||0.18|0.05|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.18||||0.18|0.12|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.18||||0.18|0.05|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|Self-pay|Self-pay|0.18||||0.18|0.06|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.18||||0.18|0.05|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.18||||0.18|0.05|0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.18||||0.18||0.12|0.05
9385|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CALCIUM CARBONATE 200 MG CALCIUM (500 MG) CHEWABLE TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.18||||0.18||0.12|0.05
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AARP [1000]|AARP [100000]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AETNA [1015]|AETNA [101529]|1.6||||1.6|0.71|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.6||||1.6|0.47|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS [1155]|BCBS UTHCT [115568]|1.6||||1.6|0.75|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.6||||1.6|0.8|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.6||||1.6|0.8|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.6||||1.6|1.01|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.6||||1.6|0.47|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|CIGNA [1260]|CIGNA GWH [126023]|1.6||||1.6|0.88|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1.6||||1.6|1.1|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.6||||1.6|0.8|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.6||||1.6|0.71|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.6||||1.6|0.47|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.6||||1.6|0.71|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.6||||1.6|0.47|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.6||||1.6|0.47|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1.6||||1.6|1.1|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.6||||1.6|0.47|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|Self-pay|Self-pay|1.6||||1.6|0.56|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.6||||1.6|0.47|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.6||||1.6|0.47|1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.6||||1.6||1.1|0.47
93931|ERX|0250 - PHARMACY-GENERAL|IPRATROPIUM-ALBUTEROL 0.5-2.5 (3) MG/3ML IN SOLN|3 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.6||||1.6||1.1|0.47
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|AARP [1000]|AARP [100000]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|AETNA [1015]|AETNA [101529]|135||||135|135|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|135||||135|40.03|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|BCBS [1155]|BCBS UTHCT [115568]|135||||135|63.45|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|135||||135|41.59|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|135||||135|67.5|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|135||||135|85.05|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|135||||135|40.03|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|CIGNA [1260]|CIGNA GWH [126023]|135||||135|74.25|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|135||||135|93.15|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|135||||135|32.79|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|135||||135|135|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|135||||135|40.03|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|135||||135|135|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|135||||135|40.03|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|135||||135|40.03|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|135||||135|93.15|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|135||||135|40.03|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|Self-pay|Self-pay|135||||135|47.25|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|135||||135|40.03|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|135||||135|40.03|135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|135||||135||135|32.79
94000396|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV 15-30MN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|135||||135||135|32.79
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|AARP [1000]|AARP [100000]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|AETNA [1015]|AETNA [101529]|240||||240|240|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|240||||240|71.16|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|240||||240|112.8|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|240||||240|82.31|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|240||||240|120|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|240||||240|151.2|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|240||||240|71.16|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|240||||240|132|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|240||||240|165.6|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|240||||240|167.04|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|240||||240|240|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|240||||240|71.16|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|240||||240|240|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|240||||240|71.16|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|240||||240|71.16|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|240||||240|165.6|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|240||||240|71.16|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|Self-pay|Self-pay|240||||240|84|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|240||||240|71.16|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|240||||240|71.16|240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|240||||240||240|71.16
94000397|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC ALCOHOL/SUBS INTERV >30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|240||||240||240|71.16
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.39||||4.39|1.94|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.39||||4.39|1.3|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.39||||4.39|2.06|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.39||||4.39|2.2|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.39||||4.39|2.2|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.39||||4.39|2.77|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.39||||4.39|1.3|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.39||||4.39|2.41|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.39||||4.39|3.03|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.39||||4.39|2.2|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.39||||4.39|1.94|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.39||||4.39|1.3|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.39||||4.39|1.94|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.39||||4.39|1.3|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.39||||4.39|1.3|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.39||||4.39|3.03|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.39||||4.39|1.3|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|Self-pay|Self-pay|4.39||||4.39|1.54|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.39||||4.39|1.3|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.39||||4.39|1.3|3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.39||||4.39||3.03|1.3
9401|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 12.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.39||||4.39||3.03|1.3
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|4.77||||4.77|2.1|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.77||||4.77|1.41|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|4.77||||4.77|2.24|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.77||||4.77|2.39|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.77||||4.77|2.39|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.77||||4.77|3.01|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.77||||4.77|1.41|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|4.77||||4.77|2.62|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|4.77||||4.77|3.29|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.77||||4.77|2.39|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.77||||4.77|2.1|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.77||||4.77|1.41|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.77||||4.77|2.1|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.77||||4.77|1.41|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.77||||4.77|1.41|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|4.77||||4.77|3.29|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.77||||4.77|1.41|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|Self-pay|Self-pay|4.77||||4.77|1.67|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.77||||4.77|1.41|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.77||||4.77|1.41|3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.77||||4.77||3.29|1.41
9402|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CAPTOPRIL 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.77||||4.77||3.29|1.41
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.82||||0.82|0.36|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.82||||0.82|0.24|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.82||||0.82|0.39|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.82||||0.82|0.41|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.82||||0.82|0.41|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.82||||0.82|0.52|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.82||||0.82|0.24|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.82||||0.82|0.45|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.82||||0.82|0.57|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.82||||0.82|0.41|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.82||||0.82|0.36|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.82||||0.82|0.24|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.82||||0.82|0.36|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.82||||0.82|0.24|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.82||||0.82|0.24|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.82||||0.82|0.57|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.82||||0.82|0.24|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|Self-pay|Self-pay|0.82||||0.82|0.29|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.82||||0.82|0.24|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.82||||0.82|0.24|0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.82||||0.82||0.57|0.24
9406|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.82||||0.82||0.57|0.24
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.59||||0.59|0.26|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.59||||0.59|0.17|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.59||||0.59|0.28|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.59||||0.59|0.3|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.59||||0.59|0.3|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.59||||0.59|0.37|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.59||||0.59|0.17|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.59||||0.59|0.32|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.59||||0.59|0.41|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.59||||0.59|0.3|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.59||||0.59|0.26|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.59||||0.59|0.17|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.59||||0.59|0.26|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.59||||0.59|0.17|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.59||||0.59|0.17|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.59||||0.59|0.41|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.59||||0.59|0.17|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|Self-pay|Self-pay|0.59||||0.59|0.21|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.59||||0.59|0.17|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.59||||0.59|0.17|0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.59||||0.59||0.41|0.17
9407|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.59||||0.59||0.41|0.17
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|AARP [1000]|AARP [100000]|381.05||||381.05|80|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|381.05||||381.05|102.53|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|AETNA [1015]|AETNA [101529]|381.05||||381.05|381.05|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|381.05||||381.05|112.98|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|381.05||||381.05|101.52|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|381.05||||381.05|101.52|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|BCBS [1155]|BCBS UTHCT [115568]|381.05||||381.05|179.09|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|381.05||||381.05|128.15|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|381.05||||381.05|190.53|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|381.05||||381.05|240.06|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|381.05||||381.05|112.98|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|381.05||||381.05|101.52|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|CIGNA [1260]|CIGNA GWH [126023]|381.05||||381.05|209.58|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|GROUP PENSION ADMIN [1450]|GPA [145000]|381.05||||381.05|262.92|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|381.05||||381.05|139.94|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|381.05||||381.05|108.73|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|381.05||||381.05|381.05|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|381.05||||381.05|112.98|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|381.05||||381.05|101.52|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|381.05||||381.05|381.05|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|381.05||||381.05|112.98|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|381.05||||381.05|112.98|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|PHCS [1780]|PHCS MULTIPLAN [178000]|381.05||||381.05|262.92|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|381.05||||381.05|112.98|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|Self-pay|Self-pay|381.05||||381.05|133.37|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|381.05||||381.05|112.98|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|381.05||||381.05|112.98|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|381.05||||381.05|80|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|381.05||||381.05|101.52|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|381.05||||381.05|101.52|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|381.05||||381.05|80|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|381.05||||381.05|101.52|381.05|80
94099195|EAP|0940 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC THERAPEUTIC PHLEBOTOMY|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|381.05||||381.05|203.04|381.05|80
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AARP [1000]|AARP [100000]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AETNA [1015]|AETNA [101529]|0.28||||0.28|0.12|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.28||||0.28|0.08|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS [1155]|BCBS UTHCT [115568]|0.28||||0.28|0.13|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.28||||0.28|0.14|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.28||||0.28|0.14|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.28||||0.28|0.18|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.28||||0.28|0.08|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|CIGNA [1260]|CIGNA GWH [126023]|0.28||||0.28|0.15|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|GROUP PENSION ADMIN [1450]|GPA [145000]|0.28||||0.28|0.19|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.28||||0.28|0.14|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.28||||0.28|0.12|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.28||||0.28|0.08|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.28||||0.28|0.12|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.28||||0.28|0.08|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.28||||0.28|0.08|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|PHCS [1780]|PHCS MULTIPLAN [178000]|0.28||||0.28|0.19|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.28||||0.28|0.08|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|Self-pay|Self-pay|0.28||||0.28|0.1|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.28||||0.28|0.08|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.28||||0.28|0.08|0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.28||||0.28||0.19|0.08
94141|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES|1 lozenge|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.28||||0.28||0.19|0.08
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|AARP [1000]|AARP [100000]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|AETNA [1015]|AETNA [101529]|107||||107|107|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|107||||107|31.73|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|107||||107|50.29|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|107||||107|66.11|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|107||||107|53.5|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|107||||107|67.41|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|107||||107|31.73|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|107||||107|58.85|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|107||||107|73.83|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|107||||107|53.5|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|107||||107|107|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|107||||107|31.73|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|107||||107|107|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|107||||107|31.73|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|107||||107|31.73|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|107||||107|73.83|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|107||||107|31.73|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|Self-pay|Self-pay|107||||107|37.45|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|107||||107|31.73|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|107||||107|31.73|107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|107||||107||107|31.73
94200108|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DM OP SMT, INDIV, PER 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|107||||107||107|31.73
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|AARP [1000]|AARP [100000]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|AETNA [1015]|AETNA [101529]|42||||42|42|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|42||||42|12.45|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|BCBS [1155]|BCBS UTHCT [115568]|42||||42|19.74|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|42||||42|17.95|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|42||||42|21|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|42||||42|26.46|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|42||||42|12.45|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|CIGNA [1260]|CIGNA GWH [126023]|42||||42|23.1|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|42||||42|28.98|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|42||||42|21|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|42||||42|42|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|42||||42|12.45|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|42||||42|42|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|42||||42|12.45|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|42||||42|12.45|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|42||||42|28.98|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|42||||42|12.45|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|Self-pay|Self-pay|42||||42|14.7|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|42||||42|12.45|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|42||||42|12.45|42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|42||||42||42|12.45
94200109|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC DIABETES GROUP EDUCATION 30 MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|42||||42||42|12.45
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|AARP [1000]|AARP [100000]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|AETNA [1015]|AETNA [101529]|67||||67|67|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|67||||67|19.87|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|BCBS [1155]|BCBS UTHCT [115568]|67||||67|31.49|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|67||||67|34.15|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|67||||67|33.5|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|67||||67|42.21|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|67||||67|19.87|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|CIGNA [1260]|CIGNA GWH [126023]|67||||67|36.85|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|67||||67|46.23|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|67||||67|33.5|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|67||||67|67|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|67||||67|19.87|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|67||||67|67|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|67||||67|19.87|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|67||||67|19.87|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|67||||67|46.23|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|67||||67|19.87|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|Self-pay|Self-pay|67||||67|23.45|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|67||||67|19.87|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|67||||67|19.87|67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|67||||67||67|19.87
94200270|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT COND CHG REASMNT IND EA 15MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|67||||67||67|19.87
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AARP [1000]|AARP [100000]|96||||96|65|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|96||||96|32.55|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AETNA [1015]|AETNA [101529]|96||||96|96|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|96||||96|28.46|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|96||||96|32.23|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|96||||96|32.23|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BCBS UTHCT [115568]|96||||96|45.12|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|96||||96|40.28|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|96||||96|48|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|96||||96|60.48|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|96||||96|28.46|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|96||||96|32.23|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|CIGNA [1260]|CIGNA GWH [126023]|96||||96|52.8|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|96||||96|66.24|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|96||||96|48|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|96||||96|32.23|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|96||||96|96|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|96||||96|28.46|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|96||||96|32.23|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|96||||96|96|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|96||||96|28.46|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|96||||96|28.46|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|96||||96|66.24|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|96||||96|28.46|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|Self-pay|Self-pay|96||||96|33.6|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|96||||96|28.46|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|96||||96|28.46|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|96||||96|65|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|96||||96|32.23|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|96||||96|32.23|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|96||||96|65|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|96||||96|32.23|96|28.46
94297802|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT INITIAL IND EA 15MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|96||||96|64.46|96|28.46
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AARP [1000]|AARP [100000]|48||||48|48|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|48||||48|27.71|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AETNA [1015]|AETNA [101529]|48||||48|48|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|48||||48|14.23|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|48||||48|27.44|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|48||||48|27.44|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BCBS UTHCT [115568]|48||||48|22.56|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|48||||48|34.15|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|48||||48|24|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|48||||48|30.24|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|48||||48|14.23|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|48||||48|27.44|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|CIGNA [1260]|CIGNA GWH [126023]|48||||48|26.4|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|48||||48|33.12|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|48||||48|24|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|48||||48|27.44|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|48||||48|48|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|48||||48|14.23|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|48||||48|27.44|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|48||||48|48|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|48||||48|14.23|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|48||||48|14.23|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|48||||48|33.12|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|48||||48|14.23|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|Self-pay|Self-pay|48||||48|16.8|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|48||||48|14.23|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|48||||48|14.23|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|48||||48|48|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|48||||48|27.44|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|48||||48|27.44|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|48||||48|48|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|48||||48|27.44|54.88|14.23
94297803|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT REASSESS IND EA 15MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|48||||48|54.88|54.88|14.23
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|AARP [1000]|AARP [100000]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|AETNA [1015]|AETNA [101529]|29||||29|29|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29||||29|8.6|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|BCBS [1155]|BCBS UTHCT [115568]|29||||29|13.63|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29||||29|18.82|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29||||29|14.5|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29||||29|18.27|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29||||29|8.6|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|CIGNA [1260]|CIGNA GWH [126023]|29||||29|15.95|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|GROUP PENSION ADMIN [1450]|GPA [145000]|29||||29|20.01|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29||||29|14.5|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29||||29|29|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29||||29|8.6|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29||||29|29|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29||||29|8.6|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|PENDING SSI [1616]|PENDING SSI RCA [161601]|29||||29|8.6|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|PHCS [1780]|PHCS MULTIPLAN [178000]|29||||29|20.01|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29||||29|8.6|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|Self-pay|Self-pay|29||||29|10.15|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29||||29|8.6|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29||||29|8.6|29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29||||29||29|8.6
94297804|EAP|0942 - OTHER THERAPEUTIC SERVICES (SEE ALSO 095X,|HC MNT GRP EA 30MIN|1|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29||||29||29|8.6
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AARP [1000]|AARP [100000]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AETNA [1015]|AETNA [101529]|19.78||||19.78|15.72|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.78||||19.78|5.86|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BCBS UTHCT [115568]|19.78||||19.78|9.3|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.78||||19.78|0|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.78||||19.78|9.89|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.78||||19.78|12.46|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.78||||19.78|5.86|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|CIGNA [1260]|CIGNA GWH [126023]|19.78||||19.78|10.88|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|19.78||||19.78|13.65|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.78||||19.78|8.49|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.78||||19.78|15.72|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.78||||19.78|5.86|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.78||||19.78|15.72|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.78||||19.78|5.86|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.78||||19.78|5.86|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|19.78||||19.78|13.65|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.78||||19.78|5.86|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|Self-pay|Self-pay|19.78||||19.78|6.92|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.78||||19.78|5.86|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.78||||19.78|5.86|15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.78||||19.78||15.72|5.86
9461|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 1 GRAM INTRAVENOUS SOLUTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.78||||19.78||15.72|5.86
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AARP [1000]|AARP [100000]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AETNA [1015]|AETNA [101529]|61.85||||61.85|31.44|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|61.85||||61.85|18.34|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BCBS UTHCT [115568]|61.85||||61.85|29.07|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|61.85||||61.85|0|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|61.85||||61.85|30.93|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|61.85||||61.85|38.97|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|61.85||||61.85|18.34|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|CIGNA [1260]|CIGNA GWH [126023]|61.85||||61.85|34.02|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|61.85||||61.85|42.68|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|61.85||||61.85|8.49|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|61.85||||61.85|31.44|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|61.85||||61.85|18.34|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|61.85||||61.85|31.44|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|61.85||||61.85|18.34|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|61.85||||61.85|18.34|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|61.85||||61.85|42.68|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|61.85||||61.85|18.34|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|Self-pay|Self-pay|61.85||||61.85|21.65|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|61.85||||61.85|18.34|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|61.85||||61.85|18.34|42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|61.85||||61.85||42.68|8.49
9463|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFOXITIN 2 GRAM INTRAVENOUS SOLUTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|61.85||||61.85||42.68|8.49
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|13.95||||13.95|9.55|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.95||||13.95|4.14|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BCBS UTHCT [115568]|13.95||||13.95|6.56|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.95||||13.95|0|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.95||||13.95|6.98|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.95||||13.95|8.79|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.95||||13.95|4.14|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA GWH [126023]|13.95||||13.95|7.67|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|13.95||||13.95|9.63|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.95||||13.95|2.48|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.95||||13.95|9.55|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.95||||13.95|4.14|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.95||||13.95|9.55|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.95||||13.95|4.14|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.95||||13.95|4.14|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|13.95||||13.95|9.63|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.95||||13.95|4.14|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|13.95||||13.95|4.88|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.95||||13.95|4.14|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.95||||13.95|4.14|9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.95||||13.95||9.63|2.48
9474|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.95||||13.95||9.63|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AARP [1000]|AARP [100000]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AETNA [1015]|AETNA [101529]|31||||31|19.1|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|31||||31|9.19|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BCBS UTHCT [115568]|31||||31|14.57|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|31||||31|0|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|31||||31|15.5|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|31||||31|19.53|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|31||||31|9.19|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|CIGNA [1260]|CIGNA GWH [126023]|31||||31|17.05|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|GROUP PENSION ADMIN [1450]|GPA [145000]|31||||31|21.39|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|31||||31|2.48|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|31||||31|19.1|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|31||||31|9.19|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|31||||31|19.1|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|31||||31|9.19|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|31||||31|9.19|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|PHCS [1780]|PHCS MULTIPLAN [178000]|31||||31|21.39|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|31||||31|9.19|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|Self-pay|Self-pay|31||||31|10.85|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|31||||31|9.19|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|31||||31|9.19|21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|31||||31||21.39|2.48
9476|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTAZIDIME 2 GRAM SOLUTION FOR INJECTION|2 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|31||||31||21.39|2.48
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AARP [1000]|AARP [100000]|4.68||||4.68|4.68|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.68||||4.68||4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AETNA [1015]|AETNA [101529]|4.68||||4.68|4.68|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.68||||4.68|1.39|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.68||||4.68||4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.68||||4.68||4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BCBS UTHCT [115568]|4.68||||4.68|2.2|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.68||||4.68|0|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.68||||4.68|2.34|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.68||||4.68|2.95|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.68||||4.68|1.39|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.68||||4.68||4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|CIGNA [1260]|CIGNA GWH [126023]|4.68||||4.68|2.57|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|GROUP PENSION ADMIN [1450]|GPA [145000]|4.68||||4.68|3.23|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.68||||4.68|0.7|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.68||||4.68||4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.68||||4.68|4.68|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.68||||4.68|1.39|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.68||||4.68||4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.68||||4.68|4.68|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.68||||4.68|1.39|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.68||||4.68|1.39|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|PHCS [1780]|PHCS MULTIPLAN [178000]|4.68||||4.68|3.23|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.68||||4.68|1.39|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|Self-pay|Self-pay|4.68||||4.68|1.64|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.68||||4.68|1.39|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.68||||4.68|1.39|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.68||||4.68|4.68|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.68||||4.68||4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.68||||4.68||4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.68||||4.68|4.68|4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.68||||4.68||4.68|0.7
9487|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 1 GRAM SOLUTION FOR INJECTION|1 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.68||||4.68||4.68|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AARP [1000]|AARP [100000]|5.24||||5.24|5.24|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.24||||5.24||5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AETNA [1015]|AETNA [101529]|5.24||||5.24|1.27|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.24||||5.24|1.55|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.24||||5.24||5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.24||||5.24||5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|BCBS [1155]|BCBS UTHCT [115568]|5.24||||5.24|2.46|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.24||||5.24|0|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.24||||5.24|2.62|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.24||||5.24|3.3|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.24||||5.24|1.55|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.24||||5.24||5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|CIGNA [1260]|CIGNA GWH [126023]|5.24||||5.24|2.88|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|5.24||||5.24|3.62|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.24||||5.24|0.7|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.24||||5.24||5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.24||||5.24|1.27|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.24||||5.24|1.55|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.24||||5.24||5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.24||||5.24|1.27|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.24||||5.24|1.55|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.24||||5.24|1.55|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|5.24||||5.24|3.62|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.24||||5.24|1.55|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|Self-pay|Self-pay|5.24||||5.24|1.83|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.24||||5.24|1.55|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.24||||5.24|1.55|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.24||||5.24|5.24|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.24||||5.24||5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.24||||5.24||5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.24||||5.24|5.24|5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.24||||5.24||5.24|0.7
9489|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 250 MG SOLUTION FOR INJECTION|250 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.24||||5.24||5.24|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AARP [1000]|AARP [100000]|2.97||||2.97|2.97|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.97||||2.97||2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AETNA [1015]|AETNA [101529]|2.97||||2.97|2.54|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.97||||2.97|0.88|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.97||||2.97||2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.97||||2.97||2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BCBS UTHCT [115568]|2.97||||2.97|1.4|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.97||||2.97|0|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.97||||2.97|1.49|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.97||||2.97|1.87|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.97||||2.97|0.88|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.97||||2.97||2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|CIGNA [1260]|CIGNA GWH [126023]|2.97||||2.97|1.63|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|2.97||||2.97|2.05|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.97||||2.97|0.7|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.97||||2.97||2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.97||||2.97|2.54|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.97||||2.97|0.88|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.97||||2.97||2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.97||||2.97|2.54|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.97||||2.97|0.88|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.97||||2.97|0.88|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|2.97||||2.97|2.05|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.97||||2.97|0.88|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|Self-pay|Self-pay|2.97||||2.97|1.04|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.97||||2.97|0.88|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.97||||2.97|0.88|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.97||||2.97|2.97|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.97||||2.97||2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.97||||2.97||2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.97||||2.97|2.97|2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.97||||2.97||2.97|0.7
9490|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CEFTRIAXONE 500 MG SOLUTION FOR INJECTION|500 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.97||||2.97||2.97|0.7
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.63||||1.63|0.72|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.63||||1.63|0.48|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.63||||1.63|0.77|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.63||||1.63|0.82|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.63||||1.63|0.82|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.63||||1.63|1.03|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.63||||1.63|0.48|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.63||||1.63|0.9|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.63||||1.63|1.12|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.63||||1.63|0.82|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.63||||1.63|0.72|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.63||||1.63|0.48|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.63||||1.63|0.72|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.63||||1.63|0.48|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.63||||1.63|0.48|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.63||||1.63|1.12|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.63||||1.63|0.48|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|Self-pay|Self-pay|1.63||||1.63|0.57|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.63||||1.63|0.48|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.63||||1.63|0.48|1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.63||||1.63||1.12|0.48
9495|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEFUROXIME AXETIL 250 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.63||||1.63||1.12|0.48
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|1.25||||1.25|0.55|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.25||||1.25|0.37|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|1.25||||1.25|0.59|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.25||||1.25|0.63|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.25||||1.25|0.63|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.25||||1.25|0.79|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.25||||1.25|0.37|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|1.25||||1.25|0.69|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|1.25||||1.25|0.86|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.25||||1.25|0.63|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.25||||1.25|0.55|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.25||||1.25|0.37|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.25||||1.25|0.55|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.25||||1.25|0.37|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.25||||1.25|0.37|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|1.25||||1.25|0.86|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.25||||1.25|0.37|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|Self-pay|Self-pay|1.25||||1.25|0.44|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.25||||1.25|0.37|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.25||||1.25|0.37|0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.25||||1.25||0.86|0.37
9499|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.25||||1.25||0.86|0.37
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.92||||0.92|0.41|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.92||||0.92|0.27|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.92||||0.92|0.43|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.92||||0.92|0.46|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.92||||0.92|0.46|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.92||||0.92|0.58|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.92||||0.92|0.27|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.92||||0.92|0.51|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.92||||0.92|0.63|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.92||||0.92|0.46|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.92||||0.92|0.41|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.92||||0.92|0.27|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.92||||0.92|0.41|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.92||||0.92|0.27|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.92||||0.92|0.27|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.92||||0.92|0.63|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.92||||0.92|0.27|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|Self-pay|Self-pay|0.92||||0.92|0.32|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.92||||0.92|0.27|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.92||||0.92|0.27|0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.92||||0.92||0.63|0.27
9500|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 500 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.92||||0.92||0.63|0.27
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AARP [1000]|AARP [100000]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AETNA [1015]|AETNA [101529]|71.3||||71.3|31.44|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|71.3||||71.3|21.14|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|71.3||||71.3|33.51|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|71.3||||71.3|35.65|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|71.3||||71.3|35.65|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|71.3||||71.3|44.92|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|71.3||||71.3|21.14|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|71.3||||71.3|39.22|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|71.3||||71.3|49.2|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|71.3||||71.3|35.65|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|71.3||||71.3|31.44|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|71.3||||71.3|21.14|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|71.3||||71.3|31.44|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|71.3||||71.3|21.14|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|71.3||||71.3|21.14|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|71.3||||71.3|49.2|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|71.3||||71.3|21.14|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|Self-pay|Self-pay|71.3||||71.3|24.95|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|71.3||||71.3|21.14|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|71.3||||71.3|21.14|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|71.3||||71.3||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|3.57||||3.57|1.57|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.57||||3.57|1.06|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|3.57||||3.57|1.68|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.57||||3.57|1.79|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.57||||3.57|1.79|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.57||||3.57|2.25|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.57||||3.57|1.06|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|3.57||||3.57|1.96|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3.57||||3.57|2.46|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.57||||3.57|1.79|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.57||||3.57|1.57|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.57||||3.57|1.06|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.57||||3.57|1.57|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.57||||3.57|1.06|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.57||||3.57|1.06|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3.57||||3.57|2.46|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.57||||3.57|1.06|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|3.57||||3.57|1.25|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.57||||3.57|1.06|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.57||||3.57|1.06|49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.57||||3.57||49.2|1.06
9502|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CEPHALEXIN 250 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.57||||3.57||49.2|1.06
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.46||||0.46|0.2|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.46||||0.46|0.14|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.46||||0.46|0.22|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.46||||0.46|0.23|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.46||||0.46|0.23|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.46||||0.46|0.29|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.46||||0.46|0.14|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.46||||0.46|0.25|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.46||||0.46|0.32|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.46||||0.46|0.23|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.46||||0.46|0.2|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.46||||0.46|0.14|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.46||||0.46|0.2|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.46||||0.46|0.14|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.46||||0.46|0.14|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.46||||0.46|0.32|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.46||||0.46|0.14|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|Self-pay|Self-pay|0.46||||0.46|0.16|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.46||||0.46|0.14|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.46||||0.46|0.14|0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.46||||0.46||0.32|0.14
9506|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CETIRIZINE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.46||||0.46||0.32|0.14
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AARP [1000]|AARP [100000]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AETNA [1015]|AETNA [101529]|0.89||||0.89|0.39|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.89||||0.89|0.26|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BCBS UTHCT [115568]|0.89||||0.89|0.42|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.89||||0.89|0.45|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.89||||0.89|0.45|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.89||||0.89|0.56|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.89||||0.89|0.26|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|CIGNA [1260]|CIGNA GWH [126023]|0.89||||0.89|0.49|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|0.89||||0.89|0.61|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.89||||0.89|0.45|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.89||||0.89|0.39|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.89||||0.89|0.26|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.89||||0.89|0.39|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.89||||0.89|0.26|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.89||||0.89|0.26|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|0.89||||0.89|0.61|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.89||||0.89|0.26|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|Self-pay|Self-pay|0.89||||0.89|0.31|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.89||||0.89|0.26|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.89||||0.89|0.26|0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.89||||0.89||0.61|0.26
9516|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLORHEXIDINE GLUCONATE 0.12 % MOUTHWASH|15 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.89||||0.89||0.61|0.26
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|AARP [1000]|AARP [100000]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|AETNA [1015]|AETNA [101529]|213.8||||213.8|94.29|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|213.8||||213.8|63.39|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|BCBS [1155]|BCBS UTHCT [115568]|213.8||||213.8|100.49|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|213.8||||213.8|106.9|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|213.8||||213.8|106.9|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|213.8||||213.8|134.69|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|213.8||||213.8|63.39|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|CIGNA [1260]|CIGNA GWH [126023]|213.8||||213.8|117.59|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|213.8||||213.8|147.52|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|213.8||||213.8|106.9|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|213.8||||213.8|94.29|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|213.8||||213.8|63.39|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|213.8||||213.8|94.29|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|213.8||||213.8|63.39|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|213.8||||213.8|63.39|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|213.8||||213.8|147.52|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|213.8||||213.8|63.39|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|Self-pay|Self-pay|213.8||||213.8|74.83|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|213.8||||213.8|63.39|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|213.8||||213.8|63.39|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|237 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|213.8||||213.8||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|AARP [1000]|AARP [100000]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|AETNA [1015]|AETNA [101529]|4.52||||4.52|1.99|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|4.52||||4.52|1.34|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|4.52||||4.52|2.12|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|4.52||||4.52|2.26|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|4.52||||4.52|2.26|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|4.52||||4.52|2.85|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|4.52||||4.52|1.34|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|4.52||||4.52|2.49|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|4.52||||4.52|3.12|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|4.52||||4.52|2.26|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|4.52||||4.52|1.99|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|4.52||||4.52|1.34|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|4.52||||4.52|1.99|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|4.52||||4.52|1.34|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|4.52||||4.52|1.34|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|4.52||||4.52|3.12|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|4.52||||4.52|1.34|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|Self-pay|Self-pay|4.52||||4.52|1.58|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|4.52||||4.52|1.34|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|4.52||||4.52|1.34|147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|4.52||||4.52||147.52|1.34
9525|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHLOROTHIAZIDE 250 MG/5 ML ORAL SUSPENSION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|4.52||||4.52||147.52|1.34
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|AARP [1000]|AARP [100000]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|AETNA [1015]|AETNA [101529]|1063.3||||1063.3|732|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1063.3||||1063.3|315.27|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|BCBS [1155]|BCBS UTHCT [115568]|1063.3||||1063.3|499.75|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1063.3||||1063.3|0|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1063.3||||1063.3|531.65|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1063.3||||1063.3|669.88|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1063.3||||1063.3|315.27|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|CIGNA [1260]|CIGNA GWH [126023]|1063.3||||1063.3|531.65|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|GROUP PENSION ADMIN [1450]|GPA [145000]|1063.3||||1063.3|733.68|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1063.3||||1063.3|7.58|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1063.3||||1063.3|732|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1063.3||||1063.3|315.27|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1063.3||||1063.3|732|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1063.3||||1063.3|315.27|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|PENDING SSI [1616]|PENDING SSI RCA [161601]|1063.3||||1063.3|315.27|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|PHCS [1780]|PHCS MULTIPLAN [178000]|1063.3||||1063.3|733.68|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1063.3||||1063.3|315.27|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|Self-pay|Self-pay|1063.3||||1063.3|372.15|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1063.3||||1063.3|315.27|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1063.3||||1063.3|315.27|733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1063.3||||1063.3||733.68|7.58
95794|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ONABOTULINUMTOXINA (COSMETIC) 50 UNIT INTRAMUSCULAR SOLUTION|1 each|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1063.3||||1063.3||733.68|7.58
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|23.25||||23.25|10.25|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|23.25||||23.25|6.89|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|23.25||||23.25|10.93|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|23.25||||23.25|11.63|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|23.25||||23.25|11.63|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|23.25||||23.25|14.65|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|23.25||||23.25|6.89|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|23.25||||23.25|12.79|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|23.25||||23.25|16.04|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|23.25||||23.25|11.63|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|23.25||||23.25|10.25|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|23.25||||23.25|6.89|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|23.25||||23.25|10.25|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|23.25||||23.25|6.89|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|23.25||||23.25|6.89|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|23.25||||23.25|16.04|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|23.25||||23.25|6.89|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|23.25||||23.25|8.14|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|23.25||||23.25|6.89|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|23.25||||23.25|6.89|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|23.25||||23.25||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|13.95||||13.95|6.15|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.95||||13.95|4.14|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|13.95||||13.95|6.56|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.95||||13.95|6.98|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.95||||13.95|6.98|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.95||||13.95|8.79|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.95||||13.95|4.14|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|13.95||||13.95|7.67|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.95||||13.95|9.63|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.95||||13.95|6.98|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.95||||13.95|6.15|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.95||||13.95|4.14|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.95||||13.95|6.15|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.95||||13.95|4.14|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.95||||13.95|4.14|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.95||||13.95|9.63|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.95||||13.95|4.14|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|13.95||||13.95|4.88|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.95||||13.95|4.14|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.95||||13.95|4.14|16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.95||||13.95||16.04|4.14
95811|ERX|0250 - PHARMACY-GENERAL|ROCURONIUM 10 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.95||||13.95||16.04|4.14
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|AARP [1000]|AARP [100000]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|AETNA [1015]|AETNA [101529]|6.33||||6.33|2.79|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6.33||||6.33|1.88|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BCBS UTHCT [115568]|6.33||||6.33|2.98|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6.33||||6.33|3.17|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6.33||||6.33|3.17|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6.33||||6.33|3.99|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6.33||||6.33|1.88|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|CIGNA [1260]|CIGNA GWH [126023]|6.33||||6.33|3.48|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|GROUP PENSION ADMIN [1450]|GPA [145000]|6.33||||6.33|4.37|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6.33||||6.33|3.17|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6.33||||6.33|2.79|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6.33||||6.33|1.88|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6.33||||6.33|2.79|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6.33||||6.33|1.88|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|PENDING SSI [1616]|PENDING SSI RCA [161601]|6.33||||6.33|1.88|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|PHCS [1780]|PHCS MULTIPLAN [178000]|6.33||||6.33|4.37|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6.33||||6.33|1.88|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|Self-pay|Self-pay|6.33||||6.33|2.22|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6.33||||6.33|1.88|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6.33||||6.33|1.88|4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6.33||||6.33||4.37|1.88
9588|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CHOLESTYRAMINE (WITH SUGAR) 4 GRAM POWDER FOR SUSP IN A PACKET|1 packet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6.33||||6.33||4.37|1.88
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AARP [1000]|AARP [100000]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AETNA [1015]|AETNA [101529]|43.4||||43.4|19.14|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|43.4||||43.4|12.87|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BCBS UTHCT [115568]|43.4||||43.4|20.4|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|43.4||||43.4|21.7|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|43.4||||43.4|21.7|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|43.4||||43.4|27.34|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|43.4||||43.4|12.87|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|CIGNA [1260]|CIGNA GWH [126023]|43.4||||43.4|23.87|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|43.4||||43.4|29.95|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|43.4||||43.4|21.7|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|43.4||||43.4|19.14|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|43.4||||43.4|12.87|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|43.4||||43.4|19.14|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|43.4||||43.4|12.87|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|43.4||||43.4|12.87|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|43.4||||43.4|29.95|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|43.4||||43.4|12.87|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|Self-pay|Self-pay|43.4||||43.4|15.19|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|43.4||||43.4|12.87|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|43.4||||43.4|12.87|29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|43.4||||43.4||29.95|12.87
9610|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CIPROFLOXACIN 0.3 % EYE DROPS|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|43.4||||43.4||29.95|12.87
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|1348.5||||1348.5|495.6|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1348.5||||1348.5|399.83|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|1348.5||||1348.5|633.8|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1348.5||||1348.5|0|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1348.5||||1348.5|674.25|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1348.5||||1348.5|849.56|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1348.5||||1348.5|399.83|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|1348.5||||1348.5|674.25|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1348.5||||1348.5|930.47|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1348.5||||1348.5|26.28|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1348.5||||1348.5|495.6|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1348.5||||1348.5|399.83|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1348.5||||1348.5|495.6|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1348.5||||1348.5|399.83|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1348.5||||1348.5|399.83|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1348.5||||1348.5|930.47|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1348.5||||1348.5|399.83|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|1348.5||||1348.5|471.97|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1348.5||||1348.5|399.83|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1348.5||||1348.5|399.83|930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1348.5||||1348.5||930.47|26.28
9615|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CLADRIBINE 10 MG/10 ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1348.5||||1348.5||930.47|26.28
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.9||||2.9|1.28|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.9||||2.9|0.86|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.9||||2.9|1.36|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.9||||2.9|1.45|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.9||||2.9|1.45|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.9||||2.9|1.83|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.9||||2.9|0.86|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.9||||2.9|1.6|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.9||||2.9|2|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.9||||2.9|1.45|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.9||||2.9|1.28|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.9||||2.9|0.86|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.9||||2.9|1.28|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.9||||2.9|0.86|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.9||||2.9|0.86|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.9||||2.9|2|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.9||||2.9|0.86|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|Self-pay|Self-pay|2.9||||2.9|1.01|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.9||||2.9|0.86|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.9||||2.9|0.86|2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.9||||2.9||2|0.86
9617|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLARITHROMYCIN 500 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.9||||2.9||2|0.86
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|36.74||||36.74|16.2|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|36.74||||36.74|10.89|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BCBS UTHCT [115568]|36.74||||36.74|17.27|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|36.74||||36.74|18.37|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|36.74||||36.74|18.37|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|36.74||||36.74|23.15|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|36.74||||36.74|10.89|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA GWH [126023]|36.74||||36.74|20.21|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|36.74||||36.74|25.35|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|36.74||||36.74|18.37|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|36.74||||36.74|16.2|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|36.74||||36.74|10.89|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|36.74||||36.74|16.2|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|36.74||||36.74|10.89|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|36.74||||36.74|10.89|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|36.74||||36.74|25.35|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|36.74||||36.74|10.89|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|36.74||||36.74|12.86|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|36.74||||36.74|10.89|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|36.74||||36.74|10.89|25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|36.74||||36.74||25.35|10.89
9626|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 600 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|36.74||||36.74||25.35|10.89
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AARP [1000]|AARP [100000]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AETNA [1015]|AETNA [101529]|44.95||||44.95|19.82|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|44.95||||44.95|13.33|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BCBS UTHCT [115568]|44.95||||44.95|21.13|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|44.95||||44.95|22.48|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|44.95||||44.95|22.48|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|44.95||||44.95|28.32|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|44.95||||44.95|13.33|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|CIGNA [1260]|CIGNA GWH [126023]|44.95||||44.95|24.72|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|44.95||||44.95|31.02|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|44.95||||44.95|22.48|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|44.95||||44.95|19.82|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|44.95||||44.95|13.33|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|44.95||||44.95|19.82|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|44.95||||44.95|13.33|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|44.95||||44.95|13.33|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|44.95||||44.95|31.02|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|44.95||||44.95|13.33|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|Self-pay|Self-pay|44.95||||44.95|15.73|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|44.95||||44.95|13.33|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|44.95||||44.95|13.33|31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|44.95||||44.95||31.02|13.33
9627|ERX|0250 - PHARMACY-GENERAL|CLINDAMYCIN 900 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK|50 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|44.95||||44.95||31.02|13.33
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.1||||0.1|0.04|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.1||||0.1|0.03|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.1||||0.1|0.05|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.1||||0.1|0.05|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.1||||0.1|0.05|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.1||||0.1|0.06|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.1||||0.1|0.03|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.1||||0.1|0.06|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.1||||0.1|0.07|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.1||||0.1|0.05|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.1||||0.1|0.04|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.1||||0.1|0.03|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.1||||0.1|0.04|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.1||||0.1|0.03|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.1||||0.1|0.03|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.1||||0.1|0.07|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.1||||0.1|0.03|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|0.1||||0.1|0.03|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.1||||0.1|0.03|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.1||||0.1|0.03|0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.1||||0.1||0.07|0.03
9637|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLONAZEPAM 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.1||||0.1||0.07|0.03
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AARP [1000]|AARP [100000]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AETNA [1015]|AETNA [101529]|8.52||||8.52|3.76|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|8.52||||8.52|2.53|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|8.52||||8.52|4|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|8.52||||8.52|4.26|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|8.52||||8.52|4.26|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|8.52||||8.52|5.37|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|8.52||||8.52|2.53|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|8.52||||8.52|4.69|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|8.52||||8.52|5.88|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|8.52||||8.52|4.26|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|8.52||||8.52|3.76|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|8.52||||8.52|2.53|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|8.52||||8.52|3.76|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|8.52||||8.52|2.53|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|8.52||||8.52|2.53|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|8.52||||8.52|5.88|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|8.52||||8.52|2.53|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|Self-pay|Self-pay|8.52||||8.52|2.98|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|8.52||||8.52|2.53|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|8.52||||8.52|2.53|5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|8.52||||8.52||5.88|2.53
9644|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOTRIMAZOLE 10 MG TROCHE|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|8.52||||8.52||5.88|2.53
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.03||||2.03|0.9|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.03||||2.03|0.6|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.03||||2.03|0.95|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.03||||2.03|1.02|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.03||||2.03|1.02|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.03||||2.03|1.28|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.03||||2.03|0.6|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.03||||2.03|1.12|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.03||||2.03|1.4|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.03||||2.03|1.02|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.03||||2.03|0.9|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.03||||2.03|0.6|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.03||||2.03|0.9|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.03||||2.03|0.6|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.03||||2.03|0.6|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.03||||2.03|1.4|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.03||||2.03|0.6|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|Self-pay|Self-pay|2.03||||2.03|0.71|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.03||||2.03|0.6|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.03||||2.03|0.6|1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.03||||2.03||1.4|0.6
9648|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CLOZAPINE 25 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.03||||2.03||1.4|0.6
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|AARP [1000]|AARP [100000]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|AETNA [1015]|AETNA [101529]|86.8||||86.8|41.18|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|86.8||||86.8|25.74|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|BCBS [1155]|BCBS UTHCT [115568]|86.8||||86.8|40.8|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|86.8||||86.8|0|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|86.8||||86.8|43.4|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|86.8||||86.8|54.68|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|86.8||||86.8|25.74|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|CIGNA [1260]|CIGNA GWH [126023]|86.8||||86.8|47.74|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|86.8||||86.8|59.89|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|86.8||||86.8|17.31|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|86.8||||86.8|41.18|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|86.8||||86.8|25.74|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|86.8||||86.8|41.18|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|86.8||||86.8|25.74|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|86.8||||86.8|25.74|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|86.8||||86.8|59.89|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|86.8||||86.8|25.74|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|Self-pay|Self-pay|86.8||||86.8|30.38|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|86.8||||86.8|25.74|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|86.8||||86.8|25.74|59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|86.8||||86.8||59.89|17.31
9681|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COLISTIN (COLISTIMETHATE SODIUM) 150 MG SOLUTION FOR INJECTION|150 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|86.8||||86.8||59.89|17.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AARP [1000]|AARP [100000]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AETNA [1015]|AETNA [101529]|330.4||||330.4|110.98|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|330.4||||330.4|97.96|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS [1155]|BCBS UTHCT [115568]|330.4||||330.4|155.29|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|330.4||||330.4|0|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|330.4||||330.4|165.2|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|330.4||||330.4|208.15|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|330.4||||330.4|97.96|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|CIGNA [1260]|CIGNA GWH [126023]|330.4||||330.4|181.72|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|330.4||||330.4|227.98|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|330.4||||330.4|40.31|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|330.4||||330.4|110.98|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|330.4||||330.4|97.96|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|330.4||||330.4|110.98|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|330.4||||330.4|97.96|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|330.4||||330.4|97.96|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|330.4||||330.4|227.98|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|330.4||||330.4|97.96|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|Self-pay|Self-pay|330.4||||330.4|115.64|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|330.4||||330.4|97.96|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|330.4||||330.4|97.96|227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|330.4||||330.4||227.98|40.31
9686|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|COSYNTROPIN 0.25 MG SOLUTION FOR INJECTION|0.25 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|330.4||||330.4||227.98|40.31
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|33.96||||33.96|14.98|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|33.96||||33.96|10.07|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|33.96||||33.96|15.96|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|33.96||||33.96|16.98|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|33.96||||33.96|16.98|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|33.96||||33.96|21.39|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|33.96||||33.96|10.07|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|33.96||||33.96|18.68|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|33.96||||33.96|23.43|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|33.96||||33.96|16.98|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|33.96||||33.96|14.98|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|33.96||||33.96|10.07|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|33.96||||33.96|14.98|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|33.96||||33.96|10.07|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|33.96||||33.96|10.07|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|33.96||||33.96|23.43|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|33.96||||33.96|10.07|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|Self-pay|Self-pay|33.96||||33.96|11.89|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|33.96||||33.96|10.07|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|33.96||||33.96|10.07|23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|33.96||||33.96||23.43|10.07
96968|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|33.96||||33.96||23.43|10.07
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|51.11||||51.11|22.54|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.11||||51.11|15.15|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|51.11||||51.11|24.02|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.11||||51.11|25.56|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.11||||51.11|25.56|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.11||||51.11|32.2|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.11||||51.11|15.15|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|51.11||||51.11|28.11|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|51.11||||51.11|35.27|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|51.11||||51.11|25.56|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.11||||51.11|22.54|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.11||||51.11|15.15|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.11||||51.11|22.54|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.11||||51.11|15.15|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|51.11||||51.11|15.15|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|51.11||||51.11|35.27|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.11||||51.11|15.15|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|Self-pay|Self-pay|51.11||||51.11|17.89|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|51.11||||51.11|15.15|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.11||||51.11|15.15|35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.11||||51.11||35.27|15.15
96970|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LACOSAMIDE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.11||||51.11||35.27|15.15
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|12.09||||12.09|1.68|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|12.09||||12.09|3.58|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|12.09||||12.09|5.68|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|12.09||||12.09|0|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|12.09||||12.09|6.05|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|12.09||||12.09|7.62|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|12.09||||12.09|3.58|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|12.09||||12.09|6.65|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|12.09||||12.09|8.34|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|12.09||||12.09|0.8|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|12.09||||12.09|1.68|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|12.09||||12.09|3.58|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|12.09||||12.09|1.68|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|12.09||||12.09|3.58|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|12.09||||12.09|3.58|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|12.09||||12.09|8.34|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|12.09||||12.09|3.58|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|12.09||||12.09|4.23|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|12.09||||12.09|3.58|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|12.09||||12.09|3.58|8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|12.09||||12.09||8.34|0.8
9707|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CYCLOSPORINE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|12.09||||12.09||8.34|0.8
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|5.05||||5.05|2.23|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.05||||5.05|1.5|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|5.05||||5.05|2.37|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.05||||5.05|2.53|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.05||||5.05|2.53|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.05||||5.05|3.18|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.05||||5.05|1.5|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|5.05||||5.05|2.78|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.05||||5.05|3.48|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.05||||5.05|2.53|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.05||||5.05|2.23|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.05||||5.05|1.5|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.05||||5.05|2.23|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.05||||5.05|1.5|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.05||||5.05|1.5|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.05||||5.05|3.48|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.05||||5.05|1.5|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|Self-pay|Self-pay|5.05||||5.05|1.77|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.05||||5.05|1.5|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.05||||5.05|1.5|3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.05||||5.05||3.48|1.5
9718|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DANTROLENE 25 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.05||||5.05||3.48|1.5
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|17.58||||17.58|7.75|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.58||||17.58|5.21|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|17.58||||17.58|8.26|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.58||||17.58|8.79|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.58||||17.58|8.79|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.58||||17.58|11.08|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.58||||17.58|5.21|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|17.58||||17.58|9.67|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.58||||17.58|12.13|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.58||||17.58|8.79|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.58||||17.58|7.75|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.58||||17.58|5.21|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.58||||17.58|7.75|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.58||||17.58|5.21|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.58||||17.58|5.21|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.58||||17.58|12.13|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.58||||17.58|5.21|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|17.58||||17.58|6.15|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.58||||17.58|5.21|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.58||||17.58|5.21|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.58||||17.58||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|AARP [1000]|AARP [100000]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|AETNA [1015]|AETNA [101529]|25.66||||25.66|11.32|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|25.66||||25.66|7.61|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BCBS UTHCT [115568]|25.66||||25.66|12.06|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|25.66||||25.66|12.83|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|25.66||||25.66|12.83|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|25.66||||25.66|16.17|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|25.66||||25.66|7.61|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|CIGNA [1260]|CIGNA GWH [126023]|25.66||||25.66|14.11|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|25.66||||25.66|17.71|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|25.66||||25.66|12.83|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|25.66||||25.66|11.32|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|25.66||||25.66|7.61|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|25.66||||25.66|11.32|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|25.66||||25.66|7.61|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|25.66||||25.66|7.61|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|25.66||||25.66|17.71|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|25.66||||25.66|7.61|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|Self-pay|Self-pay|25.66||||25.66|8.98|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|25.66||||25.66|7.61|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|25.66||||25.66|7.61|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|25 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|25.66||||25.66||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|AARP [1000]|AARP [100000]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|AETNA [1015]|AETNA [101529]|9.65||||9.65|4.26|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.65||||9.65|2.86|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BCBS UTHCT [115568]|9.65||||9.65|4.54|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.65||||9.65|4.83|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.65||||9.65|4.83|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.65||||9.65|6.08|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.65||||9.65|2.86|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|CIGNA [1260]|CIGNA GWH [126023]|9.65||||9.65|5.31|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.65||||9.65|6.66|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.65||||9.65|4.83|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.65||||9.65|4.26|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.65||||9.65|2.86|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.65||||9.65|4.26|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.65||||9.65|2.86|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.65||||9.65|2.86|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.65||||9.65|6.66|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.65||||9.65|2.86|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|Self-pay|Self-pay|9.65||||9.65|3.38|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.65||||9.65|2.86|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.65||||9.65|2.86|17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.65||||9.65||17.71|2.86
97252|ERX|0250 - PHARMACY-GENERAL|DILTIAZEM 5 MG/ML INTRAVENOUS SOLUTION|5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.65||||9.65||17.71|2.86
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.55||||19.55|8.62|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.55||||19.55|5.8|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|19.55||||19.55|9.19|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.55||||19.55|9.78|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.55||||19.55|9.78|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.55||||19.55|12.32|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.55||||19.55|5.8|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|19.55||||19.55|10.75|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.55||||19.55|13.49|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.55||||19.55|9.78|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.55||||19.55|8.62|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.55||||19.55|5.8|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.55||||19.55|8.62|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.55||||19.55|5.8|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.55||||19.55|5.8|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.55||||19.55|13.49|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.55||||19.55|5.8|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|Self-pay|Self-pay|19.55||||19.55|6.84|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.55||||19.55|5.8|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.55||||19.55|5.8|13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.55||||19.55||13.49|5.8
9726|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DEMECLOCYCLINE 150 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.55||||19.55||13.49|5.8
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AARP [1000]|AARP [100000]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AETNA [1015]|AETNA [101529]|211.21||||211.21|93.14|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|211.21||||211.21|62.62|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|211.21||||211.21|99.27|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|211.21||||211.21|105.61|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|211.21||||211.21|105.61|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|211.21||||211.21|133.06|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|211.21||||211.21|62.62|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|211.21||||211.21|116.17|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|211.21||||211.21|145.73|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|211.21||||211.21|105.61|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|211.21||||211.21|93.14|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|211.21||||211.21|62.62|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|211.21||||211.21|93.14|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|211.21||||211.21|62.62|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|211.21||||211.21|62.62|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|211.21||||211.21|145.73|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|211.21||||211.21|62.62|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|Self-pay|Self-pay|211.21||||211.21|73.92|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|211.21||||211.21|62.62|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|211.21||||211.21|62.62|145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|211.21||||211.21||145.73|62.62
97342|ERX|0250 - PHARMACY-GENERAL|SUMATRIPTAN 6 MG/0.5 ML SUBCUTANEOUS SOLUTION|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|211.21||||211.21||145.73|62.62
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AARP [1000]|AARP [100000]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AETNA [1015]|AETNA [101529]|29.45||||29.45|13.3|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|29.45||||29.45|8.73|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS [1155]|BCBS UTHCT [115568]|29.45||||29.45|13.84|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|29.45||||29.45|0|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|29.45||||29.45|14.73|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|29.45||||29.45|18.55|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|29.45||||29.45|8.73|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|CIGNA [1260]|CIGNA GWH [126023]|29.45||||29.45|16.2|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|GROUP PENSION ADMIN [1450]|GPA [145000]|29.45||||29.45|20.32|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|29.45||||29.45|3.26|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|29.45||||29.45|13.3|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|29.45||||29.45|8.73|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|29.45||||29.45|13.3|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|29.45||||29.45|8.73|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|29.45||||29.45|8.73|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|PHCS [1780]|PHCS MULTIPLAN [178000]|29.45||||29.45|20.32|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|29.45||||29.45|8.73|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|Self-pay|Self-pay|29.45||||29.45|10.31|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|29.45||||29.45|8.73|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|29.45||||29.45|8.73|20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|29.45||||29.45||20.32|3.26
97371|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|VANCOMYCIN 750 MG INTRAVENOUS SOLUTION|0.75 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|29.45||||29.45||20.32|3.26
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AARP [1000]|AARP [100000]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AETNA [1015]|AETNA [101529]|497||||497|219.18|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|497||||497|147.36|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS [1155]|BCBS UTHCT [115568]|497||||497|233.59|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|497||||497|248.5|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|497||||497|248.5|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|497||||497|313.11|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|497||||497|147.36|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|CIGNA [1260]|CIGNA GWH [126023]|497||||497|273.35|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|497||||497|342.93|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|497||||497|248.5|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|497||||497|219.18|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|497||||497|147.36|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|497||||497|219.18|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|497||||497|147.36|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|497||||497|147.36|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|497||||497|342.93|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|497||||497|147.36|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|Self-pay|Self-pay|497||||497|173.95|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|497||||497|147.36|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|497||||497|147.36|342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|497||||497||342.93|147.36
9747|ERX|0250 - PHARMACY-GENERAL|DESFLURANE 100 % INHALATION LIQUID|240 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|497||||497||342.93|147.36
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|182.26||||182.26|106.18|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|182.26||||182.26|54.04|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|182.26||||182.26|85.66|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|182.26||||182.26|0|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|182.26||||182.26|91.13|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|182.26||||182.26|114.82|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|182.26||||182.26|54.04|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|182.26||||182.26|100.24|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|182.26||||182.26|125.76|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|182.26||||182.26|13.21|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|182.26||||182.26|106.18|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|182.26||||182.26|54.04|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|182.26||||182.26|106.18|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|182.26||||182.26|54.04|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|182.26||||182.26|54.04|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|182.26||||182.26|125.76|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|182.26||||182.26|54.04|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|182.26||||182.26|63.79|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|182.26||||182.26|54.04|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|182.26||||182.26|54.04|125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|182.26||||182.26||125.76|13.21
9748|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DESMOPRESSIN 4 MCG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|182.26||||182.26||125.76|13.21
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AARP [1000]|AARP [100000]|776.74||||776.74|776.74|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|776.74||||776.74||776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|776.74||||776.74|655.2|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|776.74||||776.74|230.3|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|776.74||||776.74||776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|776.74||||776.74||776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|776.74||||776.74|365.07|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|776.74||||776.74|0|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|776.74||||776.74|388.37|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|776.74||||776.74|489.35|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|776.74||||776.74|230.3|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|776.74||||776.74||776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|776.74||||776.74|388.37|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|776.74||||776.74|535.95|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|776.74||||776.74|1.06|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|776.74||||776.74||776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|776.74||||776.74|655.2|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|776.74||||776.74|230.3|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|776.74||||776.74||776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|776.74||||776.74|655.2|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|776.74||||776.74|230.3|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|776.74||||776.74|230.3|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|776.74||||776.74|535.95|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|776.74||||776.74|230.3|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|Self-pay|Self-pay|776.74||||776.74|271.86|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|776.74||||776.74|230.3|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|776.74||||776.74|230.3|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|776.74||||776.74|776.74|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|776.74||||776.74||776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|776.74||||776.74||776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|776.74||||776.74|776.74|776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|776.74||||776.74||776.74|1.06
97788|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|EPINEPHRINE 1 MG/ML INJECTION SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|776.74||||776.74||776.74|1.06
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|11.45|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|7.75|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|11.45|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|11.45|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||11.45|4.6
9788|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND LACTATED RINGERS INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||11.45|4.6
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1400.67||||1400.67|617.7|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1400.67||||1400.67|415.3|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1400.67||||1400.67|658.31|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1400.67||||1400.67|700.34|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1400.67||||1400.67|700.34|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1400.67||||1400.67|882.42|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1400.67||||1400.67|415.3|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1400.67||||1400.67|770.37|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1400.67||||1400.67|966.46|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1400.67||||1400.67|700.34|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1400.67||||1400.67|617.7|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1400.67||||1400.67|415.3|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1400.67||||1400.67|617.7|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1400.67||||1400.67|415.3|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1400.67||||1400.67|415.3|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1400.67||||1400.67|966.46|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1400.67||||1400.67|415.3|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|Self-pay|Self-pay|1400.67||||1400.67|490.23|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1400.67||||1400.67|415.3|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1400.67||||1400.67|415.3|966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1400.67||||1400.67||966.46|415.3
97893|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|TOLVAPTAN 15 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1400.67||||1400.67||966.46|415.3
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AARP [1000]|AARP [100000]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AETNA [1015]|AETNA [101529]|27.9||||27.9|12.3|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|27.9||||27.9|8.27|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|27.9||||27.9|13.11|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|27.9||||27.9|13.95|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|27.9||||27.9|13.95|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|27.9||||27.9|17.58|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|27.9||||27.9|8.27|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|27.9||||27.9|15.35|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|27.9||||27.9|19.25|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|27.9||||27.9|13.95|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|27.9||||27.9|12.3|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|27.9||||27.9|8.27|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|27.9||||27.9|12.3|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|27.9||||27.9|8.27|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|27.9||||27.9|8.27|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|27.9||||27.9|19.25|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|27.9||||27.9|8.27|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|Self-pay|Self-pay|27.9||||27.9|9.76|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|27.9||||27.9|8.27|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|27.9||||27.9|8.27|19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|27.9||||27.9||19.25|8.27
9795|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN D5-0.9 % SODIUM CHLORIDE INTRAVENOUS|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|27.9||||27.9||19.25|8.27
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|AARP [1000]|AARP [100000]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|0.76||||0.76|0.34|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.76||||0.76|0.23|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|0.76||||0.76|0.36|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.76||||0.76|0.38|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.76||||0.76|0.38|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.76||||0.76|0.48|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.76||||0.76|0.23|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|0.76||||0.76|0.42|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|0.76||||0.76|0.52|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.76||||0.76|0.38|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.76||||0.76|0.34|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.76||||0.76|0.23|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.76||||0.76|0.34|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.76||||0.76|0.23|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.76||||0.76|0.23|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|0.76||||0.76|0.52|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.76||||0.76|0.23|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|Self-pay|Self-pay|0.76||||0.76|0.27|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.76||||0.76|0.23|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.76||||0.76|0.23|0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.76||||0.76||0.52|0.23
97953|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|OMEGA 3-DHA-EPA-FISH OIL 1,000 MG (120 MG-180 MG) CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.76||||0.76||0.52|0.23
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|6.84|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|7.75|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|7.75|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|6.84|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|6.84|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|4.6
9800|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.2 % SODIUM CHLORIDE IV|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|6.84|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|7.75|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|7.75|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|6.84|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|6.84|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|4.6
9801|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 20 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|4.6
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|AARP [1000]|AARP [100000]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA [1015]|AETNA [101529]|5.51||||5.51|2.43|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|5.51||||5.51|1.63|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|5.51||||5.51|2.59|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|5.51||||5.51|2.76|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|5.51||||5.51|2.76|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|5.51||||5.51|3.47|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|5.51||||5.51|1.63|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|5.51||||5.51|3.03|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|5.51||||5.51|3.8|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|5.51||||5.51|2.76|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|5.51||||5.51|2.43|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|5.51||||5.51|1.63|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|5.51||||5.51|2.43|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|5.51||||5.51|1.63|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|5.51||||5.51|1.63|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|5.51||||5.51|3.8|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|5.51||||5.51|1.63|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|Self-pay|Self-pay|5.51||||5.51|1.93|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|5.51||||5.51|1.63|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|5.51||||5.51|1.63|3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|5.51||||5.51||3.8|1.63
98034|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 6,000-19,000-30,000 UNIT CAPSULE,DELAYED REL|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|5.51||||5.51||3.8|1.63
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|AARP [1000]|AARP [100000]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA [1015]|AETNA [101529]|11||||11|4.85|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|11||||11|3.26|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|11||||11|5.17|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|11||||11|5.5|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|11||||11|5.5|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|11||||11|6.93|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|11||||11|3.26|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|11||||11|6.05|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|11||||11|7.59|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|11||||11|5.5|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|11||||11|4.85|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|11||||11|3.26|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|11||||11|4.85|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|11||||11|3.26|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|11||||11|3.26|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|11||||11|7.59|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|11||||11|3.26|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|Self-pay|Self-pay|11||||11|3.85|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|11||||11|3.26|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|11||||11|3.26|7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|11||||11||7.59|3.26
98035|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 12,000-38,000-60,000 UNIT CAPSULE,DELAYED REL|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|11||||11||7.59|3.26
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|AARP [1000]|AARP [100000]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|AETNA [1015]|AETNA [101529]|21.8||||21.8|9.61|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.8||||21.8|6.46|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|21.8||||21.8|10.25|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.8||||21.8|10.9|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.8||||21.8|10.9|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.8||||21.8|13.73|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.8||||21.8|6.46|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|21.8||||21.8|11.99|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|21.8||||21.8|15.04|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.8||||21.8|10.9|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.8||||21.8|9.61|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.8||||21.8|6.46|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.8||||21.8|9.61|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.8||||21.8|6.46|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.8||||21.8|6.46|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|21.8||||21.8|15.04|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.8||||21.8|6.46|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|Self-pay|Self-pay|21.8||||21.8|7.63|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.8||||21.8|6.46|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.8||||21.8|6.46|15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.8||||21.8||15.04|6.46
98036|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|LIPASE-PROTEASE-AMYLASE 24,000-76,000-120,000 UNIT CAPSULE,DELAYED REL|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.8||||21.8||15.04|6.46
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AARP [1000]|AARP [100000]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AETNA [1015]|AETNA [101529]|21.7||||21.7|9.57|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|21.7||||21.7|6.43|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|21.7||||21.7|10.2|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|21.7||||21.7|10.85|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|21.7||||21.7|10.85|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|21.7||||21.7|13.67|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|21.7||||21.7|6.43|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|21.7||||21.7|11.94|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|21.7||||21.7|14.97|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|21.7||||21.7|10.85|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|21.7||||21.7|9.57|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|21.7||||21.7|6.43|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|21.7||||21.7|9.57|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|21.7||||21.7|6.43|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|21.7||||21.7|6.43|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|21.7||||21.7|14.97|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|21.7||||21.7|6.43|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|Self-pay|Self-pay|21.7||||21.7|7.59|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|21.7||||21.7|6.43|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|21.7||||21.7|6.43|14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|21.7||||21.7||14.97|6.43
9807|ERX|0250 - PHARMACY-GENERAL|POTASSIUM CHLORIDE 40 MEQ/L IN DEXTROSE 5 %-0.45 % SODIUM CHLORIDE IV|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|21.7||||21.7||14.97|6.43
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|18.6||||18.6|4.9|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|18.6||||18.6|5.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|18.6||||18.6|8.74|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|18.6||||18.6|0|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|18.6||||18.6|9.3|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|18.6||||18.6|11.72|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|18.6||||18.6|5.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|18.6||||18.6|10.23|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|18.6||||18.6|12.83|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|18.6||||18.6|1.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|18.6||||18.6|4.9|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|18.6||||18.6|5.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|18.6||||18.6|4.9|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|18.6||||18.6|5.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|18.6||||18.6|5.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|18.6||||18.6|12.83|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|18.6||||18.6|5.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|18.6||||18.6|6.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|18.6||||18.6|5.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|18.6||||18.6|5.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|18.6||||18.6||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AARP [1000]|AARP [100000]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|13.95||||13.95|2.45|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.95||||13.95|4.14|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BCBS UTHCT [115568]|13.95||||13.95|6.56|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.95||||13.95|0|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.95||||13.95|6.98|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.95||||13.95|8.79|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.95||||13.95|4.14|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|CIGNA [1260]|CIGNA GWH [126023]|13.95||||13.95|7.67|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.95||||13.95|9.63|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.95||||13.95|1.51|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.95||||13.95|2.45|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.95||||13.95|4.14|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.95||||13.95|2.45|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.95||||13.95|4.14|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.95||||13.95|4.14|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.95||||13.95|9.63|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.95||||13.95|4.14|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|Self-pay|Self-pay|13.95||||13.95|4.88|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.95||||13.95|4.14|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.95||||13.95|4.14|12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.95||||13.95||12.83|1.51
9812|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.95||||13.95||12.83|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|4.9|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|1.51|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|4.9|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|4.9|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AARP [1000]|AARP [100000]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|13.95||||13.95|2.45|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|13.95||||13.95|4.14|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BCBS UTHCT [115568]|13.95||||13.95|6.56|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|13.95||||13.95|0|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|13.95||||13.95|6.98|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|13.95||||13.95|8.79|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|13.95||||13.95|4.14|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|CIGNA [1260]|CIGNA GWH [126023]|13.95||||13.95|7.67|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|13.95||||13.95|9.63|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|13.95||||13.95|1.51|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|13.95||||13.95|2.45|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|13.95||||13.95|4.14|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|13.95||||13.95|2.45|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|13.95||||13.95|4.14|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|13.95||||13.95|4.14|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|13.95||||13.95|9.63|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|13.95||||13.95|4.14|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|Self-pay|Self-pay|13.95||||13.95|4.88|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|13.95||||13.95|4.14|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|13.95||||13.95|4.14|10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|13.95||||13.95||10.7|1.51
9814|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.45 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|13.95||||13.95||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AARP [1000]|AARP [100000]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AETNA [1015]|AETNA [101529]|15.5||||15.5|4.9|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|15.5||||15.5|4.6|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BCBS UTHCT [115568]|15.5||||15.5|7.29|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|15.5||||15.5|0|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|15.5||||15.5|7.75|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|15.5||||15.5|9.77|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|15.5||||15.5|4.6|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|CIGNA [1260]|CIGNA GWH [126023]|15.5||||15.5|8.53|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|15.5||||15.5|10.7|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|15.5||||15.5|1.51|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|15.5||||15.5|4.9|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|15.5||||15.5|4.6|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|15.5||||15.5|4.9|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|15.5||||15.5|4.6|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|15.5||||15.5|4.6|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|15.5||||15.5|10.7|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|15.5||||15.5|4.6|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|Self-pay|Self-pay|15.5||||15.5|5.42|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|15.5||||15.5|4.6|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|15.5||||15.5|4.6|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|1,000 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|15.5||||15.5||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AARP [1000]|AARP [100000]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AETNA [1015]|AETNA [101529]|9.3||||9.3|2.45|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.3||||9.3|2.76|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BCBS UTHCT [115568]|9.3||||9.3|4.37|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.3||||9.3|0|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.3||||9.3|4.65|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.3||||9.3|5.86|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.3||||9.3|2.76|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|CIGNA [1260]|CIGNA GWH [126023]|9.3||||9.3|5.12|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|9.3||||9.3|6.42|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.3||||9.3|1.51|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.3||||9.3|2.45|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.3||||9.3|2.76|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.3||||9.3|2.45|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.3||||9.3|2.76|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.3||||9.3|2.76|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|9.3||||9.3|6.42|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.3||||9.3|2.76|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|Self-pay|Self-pay|9.3||||9.3|3.25|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.3||||9.3|2.76|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.3||||9.3|2.76|10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.3||||9.3||10.7|1.51
9815|ERX|0258 - PHARMACY-IV SOLUTIONS|DEXTROSE 5 % AND 0.9 % SODIUM CHLORIDE INTRAVENOUS SOLUTION|500 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.3||||9.3||10.7|1.51
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|AARP [1000]|AARP [100000]|170.5||||170.5|65.1|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|170.5||||170.5||117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|AETNA [1015]|AETNA [101529]|170.5||||170.5|38.16|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|170.5||||170.5|50.55|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|170.5||||170.5||117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|170.5||||170.5||117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BCBS UTHCT [115568]|170.5||||170.5|80.14|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|170.5||||170.5|0|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|170.5||||170.5|85.25|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|170.5||||170.5|107.42|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|170.5||||170.5|50.55|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|170.5||||170.5||117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|CIGNA [1260]|CIGNA GWH [126023]|170.5||||170.5|93.78|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|170.5||||170.5|117.65|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|170.5||||170.5|2.1|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|170.5||||170.5||117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|170.5||||170.5|38.16|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|170.5||||170.5|50.55|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|170.5||||170.5||117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|170.5||||170.5|38.16|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|170.5||||170.5|50.55|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|170.5||||170.5|50.55|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|170.5||||170.5|117.65|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|170.5||||170.5|50.55|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|Self-pay|Self-pay|170.5||||170.5|59.67|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|170.5||||170.5|50.55|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|170.5||||170.5|50.55|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|170.5||||170.5|65.1|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|170.5||||170.5||117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|170.5||||170.5||117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|170.5||||170.5|65.1|117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|170.5||||170.5||117.65|2.1
98249|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FLUOROURACIL 5 GRAM/100 ML INTRAVENOUS SOLUTION|100 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|170.5||||170.5||117.65|2.1
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|AARP [1000]|AARP [100000]|51.15||||51.15|23.02|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|51.15||||51.15||35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|AETNA [1015]|AETNA [101529]|51.15||||51.15|0|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|51.15||||51.15|15.17|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|51.15||||51.15||35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|51.15||||51.15||35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|BCBS [1155]|BCBS UTHCT [115568]|51.15||||51.15|24.04|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|51.15||||51.15|0|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|51.15||||51.15|25.58|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|51.15||||51.15|32.22|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|51.15||||51.15|15.17|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|51.15||||51.15||35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|CIGNA [1260]|CIGNA GWH [126023]|51.15||||51.15|28.13|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|51.15||||51.15|35.29|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|51.15||||51.15|0.23|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|51.15||||51.15||35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|51.15||||51.15|0|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|51.15||||51.15|15.17|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|51.15||||51.15||35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|51.15||||51.15|0|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|51.15||||51.15|15.17|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|51.15||||51.15|15.17|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|51.15||||51.15|35.29|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|51.15||||51.15|15.17|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|Self-pay|Self-pay|51.15||||51.15|17.9|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|51.15||||51.15|15.17|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|51.15||||51.15|15.17|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|51.15||||51.15|23.02|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|51.15||||51.15||35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|51.15||||51.15||35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|51.15||||51.15|23.02|35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|51.15||||51.15||35.29|0.23
9828|ERX|0255 - PHARMACY-DRUGS INCIDENT TO RADIOLOGY|DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION|30 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|51.15||||51.15||35.29|0.23
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|AARP [1000]|AARP [100000]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|AETNA [1015]|AETNA [101529]|3700.23||||3700.23|1631.8|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3700.23||||3700.23|1097.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|BCBS [1155]|BCBS UTHCT [115568]|3700.23||||3700.23|1739.11|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3700.23||||3700.23|0|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3700.23||||3700.23|1850.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3700.23||||3700.23|2331.14|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3700.23||||3700.23|1097.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|CIGNA [1260]|CIGNA GWH [126023]|3700.23||||3700.23|1850.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|3700.23||||3700.23|2553.16|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3700.23||||3700.23|1.16|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3700.23||||3700.23|1631.8|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3700.23||||3700.23|1097.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3700.23||||3700.23|1631.8|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3700.23||||3700.23|1097.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|3700.23||||3700.23|1097.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|3700.23||||3700.23|2553.16|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3700.23||||3700.23|1097.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|Self-pay|Self-pay|3700.23||||3700.23|1295.08|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3700.23||||3700.23|1097.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3700.23||||3700.23|1097.12|2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3700.23||||3700.23||2553.16|1.16
98312|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|FERUMOXYTOL 510 MG/17 ML (30 MG/ML) INTRAVENOUS SOLUTION|17 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3700.23||||3700.23||2553.16|1.16
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|35.72||||35.72|15.75|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|35.72||||35.72|10.59|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|35.72||||35.72|16.79|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|35.72||||35.72|17.86|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|35.72||||35.72|17.86|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|35.72||||35.72|22.5|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|35.72||||35.72|10.59|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|35.72||||35.72|19.65|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|35.72||||35.72|24.65|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|35.72||||35.72|17.86|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|35.72||||35.72|15.75|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|35.72||||35.72|10.59|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|35.72||||35.72|15.75|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|35.72||||35.72|10.59|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|35.72||||35.72|10.59|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|35.72||||35.72|24.65|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|35.72||||35.72|10.59|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|Self-pay|Self-pay|35.72||||35.72|12.5|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|35.72||||35.72|10.59|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|35.72||||35.72|10.59|24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|35.72||||35.72||24.65|10.59
98329|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONEDARONE 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|35.72||||35.72||24.65|10.59
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|3.25||||3.25|1.43|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|3.25||||3.25|0.96|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|3.25||||3.25|1.53|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|3.25||||3.25|1.63|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|3.25||||3.25|1.63|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|3.25||||3.25|2.05|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|3.25||||3.25|0.96|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|3.25||||3.25|1.79|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|3.25||||3.25|2.24|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|3.25||||3.25|1.63|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|3.25||||3.25|1.43|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|3.25||||3.25|0.96|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|3.25||||3.25|1.43|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|3.25||||3.25|0.96|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|3.25||||3.25|0.96|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|3.25||||3.25|2.24|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|3.25||||3.25|0.96|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|Self-pay|Self-pay|3.25||||3.25|1.14|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|3.25||||3.25|0.96|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|3.25||||3.25|0.96|2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|3.25||||3.25||2.24|0.96
9836|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DICLOFENAC POTASSIUM 50 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|3.25||||3.25||2.24|0.96
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.56||||2.56|1.13|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.56||||2.56|0.76|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.56||||2.56|1.2|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.56||||2.56|1.28|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.56||||2.56|1.28|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.56||||2.56|1.61|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.56||||2.56|0.76|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.56||||2.56|1.41|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.56||||2.56|1.77|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.56||||2.56|1.28|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.56||||2.56|1.13|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.56||||2.56|0.76|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.56||||2.56|1.13|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.56||||2.56|0.76|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.56||||2.56|0.76|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.56||||2.56|1.77|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.56||||2.56|0.76|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|Self-pay|Self-pay|2.56||||2.56|0.9|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.56||||2.56|0.76|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.56||||2.56|0.76|1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.56||||2.56||1.77|0.76
98372|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|PRASUGREL 5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.56||||2.56||1.77|0.76
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|AARP [1000]|AARP [100000]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|AETNA [1015]|AETNA [101529]|17509.5||||17509.5|7721.69|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17509.5||||17509.5|5191.57|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BCBS UTHCT [115568]|17509.5||||17509.5|8229.47|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17509.5||||17509.5|0|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17509.5||||17509.5|8754.75|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17509.5||||17509.5|11030.99|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17509.5||||17509.5|5191.57|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|CIGNA [1260]|CIGNA GWH [126023]|17509.5||||17509.5|9630.23|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|17509.5||||17509.5|12081.56|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17509.5||||17509.5|8754.75|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17509.5||||17509.5|7721.69|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17509.5||||17509.5|5191.57|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17509.5||||17509.5|7721.69|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17509.5||||17509.5|5191.57|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|17509.5||||17509.5|5191.57|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|17509.5||||17509.5|12081.56|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17509.5||||17509.5|5191.57|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|Self-pay|Self-pay|17509.5||||17509.5|6128.32|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17509.5||||17509.5|5191.57|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17509.5||||17509.5|5191.57|12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17509.5||||17509.5||12081.56|5191.57
98451|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO I-123 IOBENGUANE (MIBG) PER DOSE UP TO 15MCI|15 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17509.5||||17509.5||12081.56|5191.57
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|AARP [1000]|AARP [100000]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|AETNA [1015]|AETNA [101529]|102||||102|0|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102||||102|30.24|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|BCBS [1155]|BCBS UTHCT [115568]|102||||102|47.94|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102||||102|0|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102||||102|51|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102||||102|64.26|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102||||102|30.24|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|CIGNA [1260]|CIGNA GWH [126023]|102||||102|56.1|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|GROUP PENSION ADMIN [1450]|GPA [145000]|102||||102|70.38|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102||||102|51|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102||||102|0|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102||||102|30.24|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102||||102|0|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102||||102|30.24|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|PENDING SSI [1616]|PENDING SSI RCA [161601]|102||||102|30.24|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|PHCS [1780]|PHCS MULTIPLAN [178000]|102||||102|70.38|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102||||102|30.24|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|Self-pay|Self-pay|102||||102|35.7|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102||||102|30.24|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102||||102|30.24|70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102||||102||70.38|30.24
98468|ERX|0343 - NUCLEAR MEDICINE-DIAGNOSTIC RADIOPHARMACEUT|NM ISO TL-201 THALLOUS CHLORIDE PER MCI|1 millicurie|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102||||102||70.38|30.24
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AARP [1000]|AARP [100000]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|407.19||||407.19|164.54|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|407.19||||407.19|120.73|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|407.19||||407.19|191.38|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|407.19||||407.19|0|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|407.19||||407.19|203.6|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|407.19||||407.19|256.53|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|407.19||||407.19|120.73|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|407.19||||407.19|223.95|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|407.19||||407.19|280.96|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|407.19||||407.19|71.55|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|407.19||||407.19|164.54|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|407.19||||407.19|120.73|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|407.19||||407.19|164.54|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|407.19||||407.19|120.73|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|407.19||||407.19|120.73|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|407.19||||407.19|280.96|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|407.19||||407.19|120.73|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|Self-pay|Self-pay|407.19||||407.19|142.52|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|407.19||||407.19|120.73|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|407.19||||407.19|120.73|280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|407.19||||407.19||280.96|71.55
9859|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DIHYDROERGOTAMINE 1 MG/ML INJECTION SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|407.19||||407.19||280.96|71.55
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|17.3||||17.3|8.39|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|17.3||||17.3||14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|17.3||||17.3|14.3|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|17.3||||17.3|5.13|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|17.3||||17.3||14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|17.3||||17.3||14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|17.3||||17.3|8.13|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|17.3||||17.3|0|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|17.3||||17.3|8.65|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|17.3||||17.3|10.9|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|17.3||||17.3|5.13|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|17.3||||17.3||14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|17.3||||17.3|9.52|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|17.3||||17.3|11.94|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|17.3||||17.3|8.99|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|17.3||||17.3||14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|17.3||||17.3|14.3|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|17.3||||17.3|5.13|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|17.3||||17.3||14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|17.3||||17.3|14.3|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|17.3||||17.3|5.13|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|17.3||||17.3|5.13|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|17.3||||17.3|11.94|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|17.3||||17.3|5.13|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|17.3||||17.3|6.05|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|17.3||||17.3|5.13|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|17.3||||17.3|5.13|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|17.3||||17.3|8.39|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|17.3||||17.3||14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|17.3||||17.3||14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|17.3||||17.3|8.39|14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|17.3||||17.3||14.3|5.13
9892|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|DOBUTAMINE 250 MG/20 ML (12.5 MG/ML) INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|17.3||||17.3||14.3|5.13
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|9.71||||9.71|4.28|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|9.71||||9.71|2.88|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|9.71||||9.71|4.56|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|9.71||||9.71|4.86|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|9.71||||9.71|4.86|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|9.71||||9.71|6.12|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|9.71||||9.71|2.88|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|9.71||||9.71|5.34|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|9.71||||9.71|6.7|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|9.71||||9.71|4.86|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|9.71||||9.71|4.28|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|9.71||||9.71|2.88|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|9.71||||9.71|4.28|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|9.71||||9.71|2.88|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|9.71||||9.71|2.88|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|9.71||||9.71|6.7|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|9.71||||9.71|2.88|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|Self-pay|Self-pay|9.71||||9.71|3.4|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|9.71||||9.71|2.88|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|9.71||||9.71|2.88|6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|9.71||||9.71||6.7|2.88
9895|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DOXAZOSIN 2 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|9.71||||9.71||6.7|2.88
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|14.65||||14.65|2.11|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.65||||14.65|4.34|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|14.65||||14.65|6.89|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.65||||14.65|0|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.65||||14.65|7.33|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.65||||14.65|9.23|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.65||||14.65|4.34|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|14.65||||14.65|8.06|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|14.65||||14.65|10.11|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.65||||14.65|1|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.65||||14.65|2.11|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.65||||14.65|4.34|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.65||||14.65|2.11|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.65||||14.65|4.34|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.65||||14.65|4.34|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|14.65||||14.65|10.11|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.65||||14.65|4.34|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|Self-pay|Self-pay|14.65||||14.65|5.13|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.65||||14.65|4.34|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.65||||14.65|4.34|10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.65||||14.65||10.11|1
9904|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 2.5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.65||||14.65||10.11|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|AARP [1000]|AARP [100000]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|AETNA [1015]|AETNA [101529]|10.91||||10.91|4.22|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|10.91||||10.91|3.23|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|BCBS [1155]|BCBS UTHCT [115568]|10.91||||10.91|5.13|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|10.91||||10.91|0|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|10.91||||10.91|5.46|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|10.91||||10.91|6.87|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|10.91||||10.91|3.23|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|CIGNA [1260]|CIGNA GWH [126023]|10.91||||10.91|6|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|GROUP PENSION ADMIN [1450]|GPA [145000]|10.91||||10.91|7.53|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|HEALTHFIRST [2395]|HEALTHFIRST [239500]|10.91||||10.91|1|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|MAILHANDLERS [1595]|MAILHANDLERS [159500]|10.91||||10.91|4.22|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|10.91||||10.91|3.23|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|10.91||||10.91|4.22|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|10.91||||10.91|3.23|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|PENDING SSI [1616]|PENDING SSI RCA [161601]|10.91||||10.91|3.23|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|PHCS [1780]|PHCS MULTIPLAN [178000]|10.91||||10.91|7.53|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|10.91||||10.91|3.23|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|Self-pay|Self-pay|10.91||||10.91|3.82|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|10.91||||10.91|3.23|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|10.91||||10.91|3.23|7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|UMR [2035]|UMR UNITED HEALTHCARE [203502]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|10.91||||10.91||7.53|1
9905|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|DRONABINOL 5 MG CAPSULE|1 capsule|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|10.91||||10.91||7.53|1
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.56||||1.56|0.69|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.56||||1.56|0.46|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.56||||1.56|0.73|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.56||||1.56|0.78|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.56||||1.56|0.78|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.56||||1.56|0.98|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.56||||1.56|0.46|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.56||||1.56|0.86|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.56||||1.56|1.08|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.56||||1.56|0.78|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.56||||1.56|0.69|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.56||||1.56|0.46|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.56||||1.56|0.69|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.56||||1.56|0.46|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.56||||1.56|0.46|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.56||||1.56|1.08|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.56||||1.56|0.46|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|Self-pay|Self-pay|1.56||||1.56|0.55|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.56||||1.56|0.46|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.56||||1.56|0.46|1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.56||||1.56||1.08|0.46
9924|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 10 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.56||||1.56||1.08|0.46
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.22||||1.22|0.54|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.22||||1.22|0.36|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.22||||1.22|0.57|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.22||||1.22|0.61|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.22||||1.22|0.61|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.22||||1.22|0.77|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.22||||1.22|0.36|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.22||||1.22|0.67|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.22||||1.22|0.84|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.22||||1.22|0.61|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.22||||1.22|0.54|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.22||||1.22|0.36|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.22||||1.22|0.54|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.22||||1.22|0.36|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.22||||1.22|0.36|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.22||||1.22|0.84|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.22||||1.22|0.36|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.22||||1.22|0.43|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.22||||1.22|0.36|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.22||||1.22|0.36|0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.22||||1.22||0.84|0.36
9925|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ENALAPRIL MALEATE 2.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.22||||1.22||0.84|0.36
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AARP [1000]|AARP [100000]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AETNA [1015]|AETNA [101529]|14.98||||14.98|6.61|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|14.98||||14.98|4.44|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BCBS UTHCT [115568]|14.98||||14.98|7.04|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|14.98||||14.98|7.49|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|14.98||||14.98|7.49|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|14.98||||14.98|9.44|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|14.98||||14.98|4.44|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|CIGNA [1260]|CIGNA GWH [126023]|14.98||||14.98|8.24|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|14.98||||14.98|10.34|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|14.98||||14.98|7.49|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|14.98||||14.98|6.61|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|14.98||||14.98|4.44|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|14.98||||14.98|6.61|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|14.98||||14.98|4.44|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|14.98||||14.98|4.44|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|14.98||||14.98|10.34|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|14.98||||14.98|4.44|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|Self-pay|Self-pay|14.98||||14.98|5.24|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|14.98||||14.98|4.44|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|14.98||||14.98|4.44|10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|14.98||||14.98||10.34|4.44
9929|ERX|0250 - PHARMACY-GENERAL|ENALAPRILAT 1.25 MG/ML INTRAVENOUS SOLUTION|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|14.98||||14.98||10.34|4.44
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AARP [1000]|AARP [100000]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AETNA [1015]|AETNA [101529]|789.76||||789.76|348.28|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|789.76||||789.76|234.16|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BCBS UTHCT [115568]|789.76||||789.76|371.19|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|789.76||||789.76|394.88|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|789.76||||789.76|394.88|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|789.76||||789.76|497.55|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|789.76||||789.76|234.16|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|CIGNA [1260]|CIGNA GWH [126023]|789.76||||789.76|394.88|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|789.76||||789.76|544.93|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|789.76||||789.76|394.88|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|789.76||||789.76|348.28|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|789.76||||789.76|234.16|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|789.76||||789.76|348.28|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|789.76||||789.76|234.16|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|789.76||||789.76|234.16|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|789.76||||789.76|544.93|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|789.76||||789.76|234.16|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|Self-pay|Self-pay|789.76||||789.76|276.42|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|789.76||||789.76|234.16|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|789.76||||789.76|234.16|544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|789.76||||789.76||544.93|234.16
99449|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|JAPANESE ENCEPHALITIS VACCINE (PF) 6 MCG/0.5 ML INTRAMUSCULAR SYRINGE|0.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|789.76||||789.76||544.93|234.16
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|102.75||||102.75|45.31|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|102.75||||102.75|30.47|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|102.75||||102.75|48.29|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|102.75||||102.75|51.38|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|102.75||||102.75|51.38|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|102.75||||102.75|64.73|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|102.75||||102.75|30.47|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|102.75||||102.75|56.51|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|102.75||||102.75|70.9|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|102.75||||102.75|51.38|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|102.75||||102.75|45.31|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|102.75||||102.75|30.47|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|102.75||||102.75|45.31|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|102.75||||102.75|30.47|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|102.75||||102.75|30.47|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|102.75||||102.75|70.9|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|102.75||||102.75|30.47|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|Self-pay|Self-pay|102.75||||102.75|35.96|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|102.75||||102.75|30.47|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|102.75||||102.75|30.47|70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|102.75||||102.75||70.9|30.47
99456|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ILOPERIDONE 6 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|102.75||||102.75||70.9|30.47
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AARP [1000]|AARP [100000]|77.5||||77.5|77.5|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|77.5||||77.5||77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AETNA [1015]|AETNA [101529]|77.5||||77.5|36|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|77.5||||77.5|22.98|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|77.5||||77.5||77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|77.5||||77.5||77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BCBS UTHCT [115568]|77.5||||77.5|36.43|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|77.5||||77.5|0|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|77.5||||77.5|38.75|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|77.5||||77.5|48.83|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|77.5||||77.5|22.98|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|77.5||||77.5||77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|CIGNA [1260]|CIGNA GWH [126023]|77.5||||77.5|42.63|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|77.5||||77.5|53.48|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|77.5||||77.5|0.15|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|77.5||||77.5||77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|77.5||||77.5|36|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|77.5||||77.5|22.98|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|77.5||||77.5||77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|77.5||||77.5|36|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|77.5||||77.5|22.98|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|77.5||||77.5|22.98|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|77.5||||77.5|53.48|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|77.5||||77.5|22.98|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|Self-pay|Self-pay|77.5||||77.5|27.12|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|77.5||||77.5|22.98|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|77.5||||77.5|22.98|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|77.5||||77.5|77.5|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|77.5||||77.5||77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|77.5||||77.5||77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|77.5||||77.5|77.5|77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|77.5||||77.5||77.5|0.15
99610|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 50 MG/10 ML (5 MG/ML) INTRAVENOUS SOLUTION|10 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|77.5||||77.5||77.5|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AARP [1000]|AARP [100000]|558||||558|318|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|558||||558||385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AETNA [1015]|AETNA [101529]|558||||558|72|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|558||||558|165.45|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|558||||558||385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|558||||558||385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BCBS UTHCT [115568]|558||||558|262.26|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|558||||558|0|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|558||||558|279|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|558||||558|351.54|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|558||||558|165.45|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|558||||558||385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|CIGNA [1260]|CIGNA GWH [126023]|558||||558|279|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|558||||558|385.02|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|558||||558|0.15|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|558||||558||385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|558||||558|72|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|558||||558|165.45|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|558||||558||385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|558||||558|72|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|558||||558|165.45|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|558||||558|165.45|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|558||||558|385.02|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|558||||558|165.45|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|Self-pay|Self-pay|558||||558|195.3|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|558||||558|165.45|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|558||||558|165.45|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|558||||558|318|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|558||||558||385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|558||||558||385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|558||||558|318|385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|558||||558||385.02|0.15
99612|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION|20 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|558||||558||385.02|0.15
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|0.96||||0.96|0.42|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|0.96||||0.96|0.28|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|0.96||||0.96|0.45|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|0.96||||0.96|0.48|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|0.96||||0.96|0.48|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|0.96||||0.96|0.6|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|0.96||||0.96|0.28|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|0.96||||0.96|0.53|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|0.96||||0.96|0.66|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|0.96||||0.96|0.48|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|0.96||||0.96|0.42|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|0.96||||0.96|0.28|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|0.96||||0.96|0.42|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|0.96||||0.96|0.28|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|0.96||||0.96|0.28|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|0.96||||0.96|0.66|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|0.96||||0.96|0.28|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|Self-pay|Self-pay|0.96||||0.96|0.34|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|0.96||||0.96|0.28|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|0.96||||0.96|0.28|0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|0.96||||0.96||0.66|0.28
9967|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|0.96||||0.96||0.66|0.28
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AARP [1000]|AARP [100000]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AETNA [1015]|AETNA [101529]|1068.76||||1068.76|471.32|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1068.76||||1068.76|316.89|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS [1155]|BCBS UTHCT [115568]|1068.76||||1068.76|502.32|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1068.76||||1068.76|534.38|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1068.76||||1068.76|534.38|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1068.76||||1068.76|673.32|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1068.76||||1068.76|316.89|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|CIGNA [1260]|CIGNA GWH [126023]|1068.76||||1068.76|587.82|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1068.76||||1068.76|737.44|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1068.76||||1068.76|534.38|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1068.76||||1068.76|471.32|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1068.76||||1068.76|316.89|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1068.76||||1068.76|471.32|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1068.76||||1068.76|316.89|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|1068.76||||1068.76|316.89|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1068.76||||1068.76|737.44|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1068.76||||1068.76|316.89|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|Self-pay|Self-pay|1068.76||||1068.76|374.07|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1068.76||||1068.76|316.89|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1068.76||||1068.76|316.89|737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1068.76||||1068.76||737.44|316.89
9969|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ESTRADIOL 0.01% (0.1 MG/GRAM) VAGINAL CREAM|42.5 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1068.76||||1068.76||737.44|316.89
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AARP [1000]|AARP [100000]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AETNA [1015]|AETNA [101529]|6076.16||||6076.16|4504.03|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|6076.16||||6076.16|1801.58|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BCBS UTHCT [115568]|6076.16||||6076.16|2855.8|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|6076.16||||6076.16|0|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|6076.16||||6076.16|3038.08|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|6076.16||||6076.16|3827.98|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|6076.16||||6076.16|1801.58|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|CIGNA [1260]|CIGNA GWH [126023]|6076.16||||6076.16|3038.08|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|6076.16||||6076.16|4192.55|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|6076.16||||6076.16|15.15|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|6076.16||||6076.16|4504.03|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|6076.16||||6076.16|1801.58|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|6076.16||||6076.16|4504.03|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|6076.16||||6076.16|1801.58|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|6076.16||||6076.16|1801.58|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|6076.16||||6076.16|4192.55|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|6076.16||||6076.16|1801.58|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|Self-pay|Self-pay|6076.16||||6076.16|2126.66|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|6076.16||||6076.16|1801.58|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|6076.16||||6076.16|1801.58|4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|6076.16||||6076.16||4504.03|15.15
99702|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|PALIPERIDONE PALMITATE 156 MG/ML INTRAMUSCULAR SYRINGE|1 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|6076.16||||6076.16||4504.03|15.15
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AARP [1000]|AARP [100000]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AETNA [1015]|AETNA [101529]|1014.39||||1014.39|774.12|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1014.39||||1014.39|300.77|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|BCBS [1155]|BCBS UTHCT [115568]|1014.39||||1014.39|476.76|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1014.39||||1014.39|0|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1014.39||||1014.39|507.2|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1014.39||||1014.39|639.07|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1014.39||||1014.39|300.77|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|CIGNA [1260]|CIGNA GWH [126023]|1014.39||||1014.39|507.2|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|GROUP PENSION ADMIN [1450]|GPA [145000]|1014.39||||1014.39|699.93|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1014.39||||1014.39|406.89|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1014.39||||1014.39|774.12|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1014.39||||1014.39|300.77|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1014.39||||1014.39|774.12|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1014.39||||1014.39|300.77|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|PENDING SSI [1616]|PENDING SSI RCA [161601]|1014.39||||1014.39|300.77|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|PHCS [1780]|PHCS MULTIPLAN [178000]|1014.39||||1014.39|699.93|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1014.39||||1014.39|300.77|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|Self-pay|Self-pay|1014.39||||1014.39|355.04|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1014.39||||1014.39|300.77|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1014.39||||1014.39|300.77|774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1014.39||||1014.39||774.12|300.77
9972|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|CONJUGATED ESTROGENS 25 MG SOLUTION FOR INJECTION|25 mg|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1014.39||||1014.39||774.12|300.77
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.22||||19.22|8.48|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.22||||19.22|5.7|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|19.22||||19.22|9.03|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.22||||19.22|9.61|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.22||||19.22|9.61|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.22||||19.22|12.11|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.22||||19.22|5.7|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|19.22||||19.22|10.57|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.22||||19.22|13.26|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.22||||19.22|9.61|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.22||||19.22|8.48|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.22||||19.22|5.7|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.22||||19.22|8.48|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.22||||19.22|5.7|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.22||||19.22|5.7|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.22||||19.22|13.26|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.22||||19.22|5.7|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|Self-pay|Self-pay|19.22||||19.22|6.73|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.22||||19.22|5.7|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.22||||19.22|5.7|13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.22||||19.22||13.26|5.7
9973|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.3 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|19.22||||19.22|8.48|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|19.22||||19.22|5.7|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|19.22||||19.22|9.03|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|19.22||||19.22|9.61|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|19.22||||19.22|9.61|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|19.22||||19.22|12.11|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|19.22||||19.22|5.7|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|19.22||||19.22|10.57|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|19.22||||19.22|13.26|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|19.22||||19.22|9.61|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|19.22||||19.22|8.48|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|19.22||||19.22|5.7|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|19.22||||19.22|8.48|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|19.22||||19.22|5.7|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|19.22||||19.22|5.7|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|19.22||||19.22|13.26|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|19.22||||19.22|5.7|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|Self-pay|Self-pay|19.22||||19.22|6.73|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|19.22||||19.22|5.7|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|19.22||||19.22|5.7|13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|19.22||||19.22||13.26|5.7
9974|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|19.22||||19.22||13.26|5.7
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|AARP [1000]|AARP [100000]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|AETNA [1015]|AETNA [101529]|62.05||||62.05|27.36|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|62.05||||62.05|18.4|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|62.05||||62.05|29.16|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|62.05||||62.05|31.03|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|62.05||||62.05|31.03|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|62.05||||62.05|39.09|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|62.05||||62.05|18.4|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|62.05||||62.05|34.13|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|62.05||||62.05|42.81|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|62.05||||62.05|31.03|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|62.05||||62.05|27.36|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|62.05||||62.05|18.4|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|62.05||||62.05|27.36|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|62.05||||62.05|18.4|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|62.05||||62.05|18.4|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|62.05||||62.05|42.81|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|62.05||||62.05|18.4|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|Self-pay|Self-pay|62.05||||62.05|21.72|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|62.05||||62.05|18.4|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|62.05||||62.05|18.4|42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|62.05||||62.05||42.81|18.4
99755|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ASENAPINE 10 MG SUBLINGUAL TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|62.05||||62.05||42.81|18.4
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AARP [1000]|AARP [100000]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AETNA [1015]|AETNA [101529]|1252.44||||1252.44|552.33|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1252.44||||1252.44|371.35|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS [1155]|BCBS UTHCT [115568]|1252.44||||1252.44|588.65|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1252.44||||1252.44|626.22|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1252.44||||1252.44|626.22|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1252.44||||1252.44|789.04|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1252.44||||1252.44|371.35|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|CIGNA [1260]|CIGNA GWH [126023]|1252.44||||1252.44|688.84|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|GROUP PENSION ADMIN [1450]|GPA [145000]|1252.44||||1252.44|864.18|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1252.44||||1252.44|626.22|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1252.44||||1252.44|552.33|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1252.44||||1252.44|371.35|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1252.44||||1252.44|552.33|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1252.44||||1252.44|371.35|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|PENDING SSI [1616]|PENDING SSI RCA [161601]|1252.44||||1252.44|371.35|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|PHCS [1780]|PHCS MULTIPLAN [178000]|1252.44||||1252.44|864.18|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1252.44||||1252.44|371.35|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|Self-pay|Self-pay|1252.44||||1252.44|438.35|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1252.44||||1252.44|371.35|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1252.44||||1252.44|371.35|864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1252.44||||1252.44||864.18|371.35
9977|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|CONJUGATED ESTROGENS 0.625 MG/GRAM VAGINAL CREAM|30 g|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1252.44||||1252.44||864.18|371.35
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.52||||1.52|0.67|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.52||||1.52|0.45|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.52||||1.52|0.71|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.52||||1.52|0.76|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.52||||1.52|0.76|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.52||||1.52|0.96|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.52||||1.52|0.45|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.52||||1.52|0.84|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.52||||1.52|1.05|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.52||||1.52|0.76|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.52||||1.52|0.67|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.52||||1.52|0.45|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.52||||1.52|0.67|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.52||||1.52|0.45|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.52||||1.52|0.45|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.52||||1.52|1.05|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.52||||1.52|0.45|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|Self-pay|Self-pay|1.52||||1.52|0.53|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.52||||1.52|0.45|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.52||||1.52|0.45|1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.52||||1.52||1.05|0.45
998|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 0.5 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.52||||1.52||1.05|0.45
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.18||||1.18|0.52|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.18||||1.18|0.35|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.18||||1.18|0.55|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.18||||1.18|0.59|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.18||||1.18|0.59|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.18||||1.18|0.74|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.18||||1.18|0.35|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.18||||1.18|0.65|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.18||||1.18|0.81|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.18||||1.18|0.59|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.18||||1.18|0.52|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.18||||1.18|0.35|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.18||||1.18|0.52|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.18||||1.18|0.35|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.18||||1.18|0.35|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.18||||1.18|0.81|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.18||||1.18|0.35|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|Self-pay|Self-pay|1.18||||1.18|0.41|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.18||||1.18|0.35|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.18||||1.18|0.35|0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.18||||1.18||0.81|0.35
9982|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 100 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.18||||1.18||0.81|0.35
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|2.42||||2.42|1.07|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|2.42||||2.42|0.72|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|2.42||||2.42|1.14|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|2.42||||2.42|1.21|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|2.42||||2.42|1.21|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|2.42||||2.42|1.52|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|2.42||||2.42|0.72|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|2.42||||2.42|1.33|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|2.42||||2.42|1.67|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|2.42||||2.42|1.21|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|2.42||||2.42|1.07|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|2.42||||2.42|0.72|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|2.42||||2.42|1.07|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|2.42||||2.42|0.72|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|2.42||||2.42|0.72|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|2.42||||2.42|1.67|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|2.42||||2.42|0.72|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|Self-pay|Self-pay|2.42||||2.42|0.85|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|2.42||||2.42|0.72|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|2.42||||2.42|0.72|1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|2.42||||2.42||1.67|0.72
9983|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|ETHAMBUTOL 400 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|2.42||||2.42||1.67|0.72
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|AARP [1000]|AARP [100000]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|AETNA [1015]|AETNA [101529]|1023.79||||1023.79|1023.79|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1023.79||||1023.79|303.55|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|BCBS [1155]|BCBS UTHCT [115568]|1023.79||||1023.79|481.18|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1023.79||||1023.79|0|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1023.79||||1023.79|511.9|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1023.79||||1023.79|644.99|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1023.79||||1023.79|303.55|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|CIGNA [1260]|CIGNA GWH [126023]|1023.79||||1023.79|511.9|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|GROUP PENSION ADMIN [1450]|GPA [145000]|1023.79||||1023.79|706.42|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1023.79||||1023.79|555.13|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1023.79||||1023.79|1023.79|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1023.79||||1023.79|303.55|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1023.79||||1023.79|1023.79|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1023.79||||1023.79|303.55|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|PENDING SSI [1616]|PENDING SSI RCA [161601]|1023.79||||1023.79|303.55|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|PHCS [1780]|PHCS MULTIPLAN [178000]|1023.79||||1023.79|706.42|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1023.79||||1023.79|303.55|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|Self-pay|Self-pay|1023.79||||1023.79|358.33|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1023.79||||1023.79|303.55|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1023.79||||1023.79|303.55|1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1023.79||||1023.79||1023.79|303.55
9984|ERX|0636 - PHARMACY-EXTENSION OF 025X-DRUGS REQUIRING|ETHANOLAMINE OLEATE 5 % INTRAVENOUS SOLUTION|1.5 mL|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1023.79||||1023.79||1023.79|303.55
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AARP [1000]|AARP [100000]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AETNA MEDICARE REPLACEMENT [1020]|AETNA MEDICARE REPLACEMENT [102002]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AETNA [1015]|AETNA [101529]|1.52||||1.52|0.67|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICAID [1095]|AMERIGROUP MEDICAID [109500]|1.52||||1.52|0.45|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|AMERIGROUP MEDICARE [1100]|AMERIGROUP MEDICARE [110000]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS MEDICARE REPLACEMENT [1160]|BLUE CROSS MEDICARE ADVANTAGE OOS [116005]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS [1155]|BCBS UTHCT [115568]|1.52||||1.52|0.71|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS ADVANTAGE HMO OF TEXAS [115525]|1.52||||1.52|0.76|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS HMO OF TEXAS [115504]|1.52||||1.52|0.76|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|BCBS [1155]|BLUE CROSS PREFERRED PPO OF TEXAS [115526]|1.52||||1.52|0.96|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|CIGNA MEDICAID REPLACEMENT [3945]|CIGNA HEALTHSPRING MEDICAID REPLACEMENT [394500]|1.52||||1.52|0.45|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|CIGNA MEDICARE REPLACEMENT [1265]|CIGNA MEDICARE REPLACEMENT [126500]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|CIGNA [1260]|CIGNA GWH [126023]|1.52||||1.52|0.84|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|GROUP PENSION ADMIN [1450]|GPA [145000]|1.52||||1.52|1.05|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|HEALTHFIRST [2395]|HEALTHFIRST [239500]|1.52||||1.52|0.76|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|HUMANA MEDICARE REPLACEMENT [1525]|HUMANA MEDICARE ADVANTAGE/PPO/GOLD [152503]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MAILHANDLERS [1595]|MAILHANDLERS [159500]|1.52||||1.52|0.67|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MANAGED MEDICAID [3845]|MANAGED MEDICAID OTHER [384500]|1.52||||1.52|0.45|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MANAGED MEDICARE [1600]|MANAGED MEDICARE OTHER [160000]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MERITAIN AETNA [3685]|MERITAIN AETNA [368500]|1.52||||1.52|0.67|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|MOLINA CENTENNIAL CARE [2255]|MOLINA CENTENNIAL CARE MEDICAID REPL [225500]|1.52||||1.52|0.45|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|PENDING SSI [1616]|PENDING SSI RCA [161601]|1.52||||1.52|0.45|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|PHCS [1780]|PHCS MULTIPLAN [178000]|1.52||||1.52|1.05|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|STAR SUPERIOR MEDICAID [1945]|SUPERIOR CHIP [194501]|1.52||||1.52|0.45|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|Self-pay|Self-pay|1.52||||1.52|0.53|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|TEXAS CHILDRENS HEALTH PLAN [3995]|TEXAS CHILDRENS HEALTH PLAN [399500]|1.52||||1.52|0.45|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|UHC MEDICAID REPLACEMENT [3755]|UHC MEDICAID COMMUNITY PLAN [375501]|1.52||||1.52|0.45|1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|UMR [2035]|UMR UNITED HEALTHCARE [203502]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|UNITED BEHAVIORAL MANAGED MEDICARE [2201]|UNITED MANAGED MEDICARE BEHAVIORAL [220100]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE MEDICARE REPLACEMENT [2065]|UHC MEDICARE ADVANTAGE [206511]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|UNITED HEALTHCARE [2060]|UHC MEDICA CHOICE [206030]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|WELLCARE MEDICARE REPLACEMENT [3775]|WELLCARE MEDICARE [377501]|1.52||||1.52||1.05|0.45
999|ERX|0637 - PHARMACY-EXTENSION OF 025X-SELF-ADMINISTRAB|BENZTROPINE 1 MG TABLET|1 tablet|WORKER'S COMP [2125]|TEXAS A&M UNIVERSITY RISK MGT [2125109]|1.52||||1.52||1.05|0.45